New Patient Info/Consent Form 

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New Patient Info/Consent Form 

If you prefer to download this form in PDF format, please download here

patient contact information

tell us about yourself

Consent for Treatment

I hereby consent to and authorize The MedSpa @RPSC. to perform the following procedure(s): chemical peels, dermaplane, micro-needling, facials, waxing, make-up application, extractions, all aesthetic services, product recommendations, and any other procedures recommended.

The nature and the purpose of the treatment(s) have been explained to me, along with the risks and hazards involved by The MedSpa @RPSC, and I have voluntarily elected to undergo the treatment/procedure(s).
I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost have been explained to me.

I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post- treatment care, I will consult The MedSpa @RPSC. immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure(s) and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the aesthetician or The MedSpa @RPSC. whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today or any future treatments.
The MedSpa @RPSC. Policies.

A 24-hour cancellation notification is required to avoid a cancellation fee of $25. No refunds and/or exchanges on retail products

For safety reasons, children are not allowed in the treatment room or left unattended in The MedSpa

Smoking Risk Consent

The MedSpa in conjunction with Raleigh Plastic Surgery Center stands by their commitment in providing information, products, and services to achieve the best possible cosmetic outcome.
The MedSpa @RPSC recommends smokers abstain from nicotine or nicotine substitutes for a minimum of 6 weeks before and after in office procedures and treatments. Carcinogens from smoke and secondhand smoke may impact your treatment and desired end result.
There is greater risk in smokers for bad scarring, hemotoma formation, intraoperative bleeding, bleeding, poor or delayed healing, hair loss, sloughing of the skin (skin loss), infection, increased or prolonged bruising and hyperpigmentation.

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