New Patient Medical Consent Forms:

We are delighted you’ve chosen us for your aesthetic and wellness journey. Our team is committed to providing you with the safest, most effective treatments. Please complete this intake and consent packet so we may better serve you.

Patient Information

Last Name

First Name

Date of birth *

Phone *

Email *

Address

Street Address *

City *

State *

Zip Code *

Referred By

Occupation

Medical History Questionnaire & Consent

Is your general health good? *

Yes

Date of last physical:

Please check any conditions that apply:

Diabetes

High Blood Pressure

Heart Disease

Epilepsy

Asthma

Hepatitis

Kidney Disease

Liver Disease

Thyroid Disease

Bleeding Disorders

Other

Photography Consent

I understand that photographs may be taken before, during, and after my procedures at Bratz Med Spa. These photographs may be used for documentation, treatment planning, and marketing purposes.

Please select one option: *

I consent to the taking and use of photographs as described.

I decline the taking and use of photographs as described.

Date

Signature:

Clear

Notice of Privacy Practices (HIPAA)

I acknowledge receipt of Bratz Med Spa’s Notice of Privacy Practices and consent to the use and disclosure of my health information for treatment, payment, and healthcare operations.

Date:

Signature

Clear

General Consent for Treatment

I hereby request and consent to treatments and procedures provided by Bratz Med Spa. I understand the nature, purpose, risks, and potential complications and consent to proceed with services as recommended.

Date

Signature

Clear