Consent Form - Beauty Mantra

Patient Full Name *

Sex *

Male
Female
Other

Date of Birth *

Email *

Phone *

2. ALLERGIES & SENSITIVITIES

Do you have any known allergies? (e.g., latex, aspirin, nuts, fragrances, ingredients)

Have you reacted to skincare or treatments before? *

If yes, describe:

3. CURRENT MEDICATIONS & SUPPLEMENTS

Please list all medications, vitamins, or supplements you are currently taking:

Do you currently use or have recently used:

Roaccutane/Accutane (isotretinoin)
Retinoids (e.g., retinol, tretinoin)?
Blood thinners (aspirin, warfarin)?
Hormonal therapies (birth control, HRT)?

Other:

6. CURRENT SKINCARE ROUTINE

Please list products you're currently using (include brands if known):

Morning Routine:

Cleanser:

Serum(s)

Moisturiser:

SPF:

Other:

Evening Routine:

Cleanser:

Serum(s)

Moisturiser:

Other:

7. RECENT TREATMENTS / COSMETIC PROCEDURES

Have you had any treatments or cosmetic procedures in the last 4 weeks? (e.g., peels, microneedling, laser, injectables) *

If yes, list type and date:

8. CONSENT & ACKNOWLEDGEMENT

I confirm that: *

The information I have provided is complete and accurate to the best of my knowledge
I understand that results from treatments may vary based on individual skin types, conditions, and compliance with post-treatment care.
All relevant medical and skin history including medications, allergies and sensitivities I have disclosed.
I understand that there can be potential temporary side effects such as redness, sensitivity, or minor irritation.
I will follow all aftercare advice provided by the therapist or practitioner.
I give my informed consent to receive skin treatment(s) today.

Client Signature:

Date

Doctor or Dermal Clinicians Name:

Doctor or Dermal Clinicians Signature:

Date

Beauty Mantra Skin Treatment Patient Consent Form

1. MEDICAL HISTORY

2. ALLERGIES & SENSITIVITIES

Do you have any known allergies? (e.g., latex, aspirin, nuts, fragrances, ingredients)

3. CURRENT MEDICATIONS & SUPPLEMENTS

Please list all medications, vitamins, or supplements you are currently taking:

4. SKIN CONDITIONS

5. MAIN SKIN CONCERNS

6. CURRENT SKINCARE ROUTINE

Morning Routine:

Evening Routine:

7. RECENT TREATMENTS / COSMETIC PROCEDURES

8. CONSENT & ACKNOWLEDGEMENT

Free Skin Consultation & AI Skin Analysis