Client Consent Forms | Sorellina Clinic

Personal Information

Full Name *

Date of Birth *

Email *

Phone

Treatment Area(s)

Practitioner

Medical History — Tick all that apply

Current medications

Known allergies

Consent Declaration

Signature

Sign using mouse or finger

Type your full name *

Full Name *

Date of Birth *

Email *

Treatment Area(s)

Medical History — Tick all that apply

Pregnant / breastfeeding Neuromuscular disorder Allergy to botulinum toxin Bleeding disorders Blood thinning medications Antibiotics (last 2 weeks) Autoimmune condition Dental work (last 2 weeks) Herpes simplex / cold sores

Consent Declaration

Signature

Sign using mouse or finger

Type your full name *

Full Name *

Email *

Treatment Area(s)

Medical History — Tick all that apply

Pregnant / breastfeeding Allergy to hyaluronic acid Allergy to lidocaine Active cold sore / herpes Blood thinning medication Autoimmune condition Recent dental work (4 wks) Roaccutane (last 6 months)

Consent Declaration

Signature

Sign using mouse or finger

Full name *

Full Name *

Email *

Treatment

Consent Declaration

Signature

Sign using mouse or finger

Full name *

Full Name *

Email *

Treatment

Consent Declaration

Signature

Sign using mouse or finger

Full name *

Full Name *

Email *

Treatment

Consent Declaration

Signature

Sign using mouse or finger

Full name *

Full Name *

Email *

Service Required

Recent chemical treatments

Consent Declaration

Signature

Sign using mouse or finger

Full name *