med spa intake form template

Medical Aesthetic Services Patient Intake and Consent Form

Instructions for Use

• Complete all sections of this form accurately; incomplete information may delay your scheduled service or compromise safety.
• Ensure the patient reviews the medical history and contraindications sections thoroughly before signing.
• Retain a signed copy for your practice's medical records and provide a duplicate to the patient upon request.

Parties & Definitions

This Intake and Consent Form ("Agreement") is entered into by and between [Practice Name], located at [Practice Address] ("Provider"), and [Patient Full Legal Name], residing at [Patient Address] ("Patient").

Operative Clauses

1. Medical History Disclosure: The Patient certifies that the medical history provided below is accurate and complete. The Patient agrees to notify the Provider of any changes in medical status, medications, or health conditions prior to any future treatments.

   • No known allergies
   • Allergies: [__________]
   • Current medications: [__________]
   • History of skin conditions or scarring: [__________]

2. Informed Consent: The Patient acknowledges that they have been informed of the nature of the aesthetic procedures, the expected results, and the potential risks/side effects, including but not limited to: [__________]. The Patient understands that results vary and are not guaranteed.

3. Financial Responsibility: The Patient agrees to pay for all services rendered at the time of the appointment. A cancellation fee of $[] will be charged if the Patient fails to provide at least [] hours' notice for cancellations.

4. Privacy and HIPAA Compliance: Provider agrees to maintain the confidentiality of the Patient’s protected health information in accordance with applicable state and federal laws. A copy of the Notice of Privacy Practices is available upon request.

5. Photographic Records: The Patient [ ] grants / [ ] denies permission for the Provider to take clinical photographs for the purpose of documenting treatment progress. These photographs shall remain the property of the Provider and will be kept confidential.

6. Governing Law: This Agreement shall be governed by the laws of the State of [__________].

Signature & Acknowledgment

By signing below, I acknowledge that I have read, understood, and voluntarily agreed to the terms of this intake form and the associated consent for treatment.

Signature: __________

Printed Name: [__________]

Title/Relationship (if signing for minor): [__________]

Date: [__________]

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Requirements for medical aesthetic practices vary significantly by state and local jurisdiction. Consult with qualified legal counsel to ensure compliance with medical board regulations, HIPAA, and state-specific informed consent statutes.