Client Consent Form | SkinCity.519

Website

Treatment Areas

Select all areas the client would like treated.

Other treatment area details

Primary concerns / notes

Medical History

Please answer every question accurately for treatment safety.

Medications list (include last taken dates when relevant)

Other medical notes

Fitzpatrick Skin Type Evaluator

Select the option that best describes you for each question.

Genetic Disposition

What is your natural eye color?*

What is your natural hair color?*

What is the color of your non-exposed skin?*

Do you have freckles on areas not exposed to sun?*

Reaction to Sun Exposure

What happens when you stay in the sun too long?*

To what degree do you turn brown?*

Do you turn brown within several hours after sun exposure?*

How does your face react to the sun?*

Tanning Habits

When did you last expose your body to sun, a tanning bed, or tanning cream?*

Do you wear sunscreen or protect your face every time you are outside?*

Fitzpatrick score guide

Total score is calculated from your selections and included in the email submission. Typical ranges: 0-7 (Type I), 8-16 (Type II), 17-25 (Type III), 26-30 (Type IV), over 30 (Type V-VI).

Treatment Consent & Risk Acknowledgment

Please review and confirm the treatment risks and acknowledgments below.

Possible experiences / risks

Discomfort may be experienced during laser treatment.
Healing can involve swelling, redness, blistering, crusting, scabs, or flaking and may take days to weeks.
Bruising, swelling, and rare infection are possible if treated skin becomes contaminated or not cared for properly.
Pigment changes (lighter or darker skin) can occur and may be temporary or permanent.
Scarring is rare but possible, and aftercare instructions must be followed carefully.
Protective eyewear must remain on during treatment to prevent accidental eye exposure.

Client initials (risk acknowledgment)*

Acknowledgment statements

I understand treatments may not meet my expectations.I understand an imperfection might occur.I understand the risks/complications during the procedure and healing period (including infection, scarring, crusting, regrowth of hair, and/or blistering).I understand exposure to laser light could harm my vision and I must keep eye protection on at all times.I have read and understood post-treatment instructions.I freely assume the risks and release SkinCity Laser Studio from liability related to the treatment, to the extent permitted by law.

Additional consent notes (optional)

Photo & Video Release

Choose whether you authorize SkinCity to use photo/video/audio content for promotional purposes.

I grant / do not grant authorization to use my photos, videos, and/or audio recordings for lawful promotional materials (website, social media, print/digital marketing, etc.).

I grant authorizationI do not grant authorization

By submitting this form, you acknowledge the release statement and your choice above.

Digital Signatures

This signature applies to the consultation form, treatment consent, and photo/video release choices provided above.

Client name*

Date*

Client signature box*

This drawn signature will be reused across the client signature lines in the generated PDF copy.

Draw with your finger or stylus.Not signed

I confirm that the information provided is true and complete to the best of my knowledge, and I agree that my name above and the drawn signature box serve as my electronic signature for this consent submission.

Parent / Guardian (if minor)

These fields remain optional unless the client is a minor.

Optional

Parent/Guardian print name

Parent/Guardian typed name (optional)

Parent/Guardian date

Review & Submit

Confirm key details before sending the completed consent package to SkinCity.

Client

Name: —
Email: —
Phone: —
DOB: —

Selected Areas

No treatment areas selected yet.

Consent Status

Photo release: Not selected
Client drawn signature: Missing
Guardian drawn signature: Not required
Medical conditions selected: 0

Client Consultation & Consent Form

Client Information