Classic form

Cosmetic treatment consent form with an eight item risks checklist

A cosmetic treatment consent form records that a client understood the treatment, its risks and the alternatives before agreeing to it. This one, for a skin clinic offering peels and microneedling, lists eight risks to tick, then asks about alternatives, aftercare and before and after photos before the client signs.

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Treatment consent

Lirrabelle Aesthetics. Please complete this after your consultation and before your first treatment. Your practitioner has explained the treatment, its risks and the alternatives; this form records that you understood them.
Health details are seen only by your practitioner and kept with your treatment record.

Every field, and what it collects

The complete field list, in the order respondents meet it.

Client nameNameRequired
Date of birthDateRequired
TreatmentDropdownRequired
Options: Chemical peel, light · Chemical peel, medium · Microneedling · LED light therapy · Microdermabrasion · Hydrating facial infusion
Do any of these apply to you?Multiple choiceRequired
Options: Pregnant or breastfeeding · Acne medicine taken by mouth in the last 6 months · Active cold sores or skin infection · History of keloid or raised scars · Recent sun exposure or tanning · None of these
I have read and understood these possible risks:Multiple choiceRequired
Options: Redness and swelling for hours to days · Peeling, flaking or dryness · Darker or lighter patches of skin · Breakouts after treatment · Cold sore flare up · Infection · Scarring, which is rare · Results that differ from what I expected
Did your practitioner discuss alternatives, including no treatment?Single choiceRequired
Options: Yes · No, I would like to discuss them first
Have you received written aftercare instructions?Single choiceRequired
Options: Yes, I have them · No, please send them
Before and after photosSingle choiceRequired
Options: For my clinical record only · For my record and, without my face, for the clinic's marketing · No photos
Practitioner nameShort textRequired
SignatureSignatureRequired
DateDateRequired

What each field on this form collects

The client's name sits beside date of birth. The treatment dropdown lists six skin treatments. A privacy paragraph introduces a health checkbox of five items and "none of these", including acne medicine taken by mouth, which affects healing. The risks checkbox lists eight possible outcomes, from redness to scarring and results that differ from expectations. Alternatives, aftercare and photos are three radios, each with an answer that pauses the process. The practitioner's name is short text, and the signature and date share the last row. All eleven fields are required.

Why every risk is a separate tick

A paragraph of risks followed by one signature proves only that a client signed. Eight ticks, one per risk, show that each was put in front of them, including the two clients most often say nobody mentioned: darker or lighter patches of skin, and results that differ from what they hoped. The form cannot force every box to be ticked, so the practitioner checks the response before treating and talks through anything left blank. The radios work the same way. "No, I would like to discuss them first" on alternatives is a reason to pause, not a box to argue with.

What the practitioner checks before treating

Before the first treatment, the practitioner opens the response and checks four things: every risk ticked, the health answers, the alternatives answer and the photo choice. A blank risk or a pause answer means a conversation before anything starts. A yes on acne medicine, cold sores or recent tanning can mean postponing. The practitioner's name on the form ties the consent to the consultation it followed, which matters if a question is ever raised about what the client was told.

How to adapt this form

A clinic offering laser or light based treatments adds skin type and recent sun exposure, as the laser hair removal form on this site does. A clinic run by a registered medical practitioner adds a cooling off period field and a referral history. A spa doing only facials can drop the risk list to the four items that apply.

What makes this form work

Eight risks, eight ticks

Redness, peeling, pigment change, breakouts, cold sores, infection, scarring and unexpected results are each ticked, so the record shows every risk was put in front of the client.

Answers that pause the process

"I would like to discuss them first" for alternatives and "please send them" for aftercare give the client a way to say not yet without refusing treatment.

Photos with three clear choices

Clinical record only, faceless marketing use or no photos keeps marketing consent separate from consent to the treatment itself.

Questions people ask

What should a cosmetic treatment consent form include?

The treatment, the client's relevant health history, the material risks in plain words, the alternatives including doing nothing, aftercare, any photography, the practitioner's name and the client's signature and date. This form covers each in that order. Consent also needs a conversation: the form records that the consultation happened, it does not replace it.

Why ask about acne medicine taken by mouth?

Some oral acne treatments change how skin heals, and practitioners often wait months after a course ends before peels or microneedling. The form asks about the last six months in plain words rather than naming a medicine, and the practitioner follows up with the client and, if needed, their doctor.

Can a client refuse before and after photos?

Yes. The photo question offers clinical record only, record plus faceless marketing use, or no photos at all. Photos help track results and resolve disputes, so many clinics encourage the first option, but marketing use must be a separate choice, never assumed from consent to treatment.

What is a cooling off period?

Time between the consultation and the treatment so the client can think it over without pressure. The thank-you screen promises at least one day. For some procedures in some places a cooling off period is required by professional guidance; for most skin treatments it is simply good practice that reduces regret and complaints.

Does the practitioner need to sign too?

Many clinics have the practitioner countersign in the treatment notes. This form records the practitioner's name so the response shows who did the consultation. A clinic that wants a second signature on the same record can add one beside the client's, labelled for the practitioner.

How long is cosmetic treatment consent valid?

For the course of treatment described, as long as nothing changes. A new treatment, a change in health such as pregnancy or new medication, or a long gap between sessions calls for a fresh form. The date field makes the age of each consent obvious in the client's record.

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Sources

Written and checked by the OneCraft team. Last checked .