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Printable Facial Intake Form

Printable Facial Intake Form Template for South Africa

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Key Requirements PROMPT example:

Printable Facial Intake Form

"I need a comprehensive Printable Facial Intake Form for my new medical aesthetic clinic opening in March 2025 in Johannesburg, with detailed sections for medical history and incorporating advanced skin analysis documentation, suitable for both cosmetic and medical-grade treatments."

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Document background
The Printable Facial Intake Form is a crucial document used in South African aesthetic practices, beauty salons, and medical spas to gather essential information before providing facial treatments. It serves multiple purposes: collecting client personal and medical information, documenting informed consent, and maintaining compliance with South African regulations, particularly POPIA and healthcare requirements. This document should be completed by all new clients before their first treatment and updated periodically to ensure information accuracy. It includes sections for personal details, medical history, skin assessment, and treatment consent, making it an essential risk management and client care tool. The form helps practitioners make informed decisions about treatment suitability while protecting both the client and the business through proper documentation and disclosure.
Suggested Sections

1. Personal Information: Client's basic details including full name, ID number, contact information, and address as required by POPIA

2. Emergency Contact Information: Details of person to contact in case of emergency, including relationship to client

3. Medical History: Comprehensive medical history including allergies, current medications, chronic conditions, and recent surgeries

4. Skin Assessment: Current skin conditions, concerns, and treatment history

5. Lifestyle Factors: Relevant lifestyle information including sun exposure, smoking, skincare routine

6. Treatment History: Previous facial treatments, reactions, and outcomes

7. Photographs and Documentation: Consent for before/after photographs and documentation

8. Informed Consent: Detailed treatment consent, risks acknowledgment, and liability provisions

9. Privacy Notice: POPIA-compliant privacy statement explaining how personal information will be used and protected

Optional Sections

1. Pregnancy Status: Required for clients who may be pregnant or nursing, as certain treatments may be contraindicated

2. Current Skincare Products: Detailed list of current skincare products when needed for treatment planning

3. Payment Information: Section for payment details and policies when required by the establishment

4. Insurance Information: Required when treatments might be claimed through medical insurance

5. COVID-19 Screening: Temporary section for pandemic-related health screening when required by regulations

Suggested Schedules

1. Treatment Price List: Current pricing for all available treatments

2. Treatment Aftercare Instructions: Standard aftercare instructions for various treatments offered

3. Medical Conditions Checklist: Detailed checklist of medical conditions that may affect treatment

4. Skin Type Classification Guide: Fitzpatrick scale and skin type assessment guide

5. Product Sensitivity Test Record: Form for recording results of patch tests and sensitivity assessments

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓƵ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions






























Clauses




















Relevant Industries

Healthcare

Beauty and Wellness

Medical Aesthetics

Cosmetic Services

Spa and Recreation

Dermatology

Professional Beauty

Relevant Teams

Operations

Front Desk

Clinical

Administration

Compliance

Customer Service

Medical Records

Treatment

Quality Assurance

Relevant Roles

Aesthetician

Beauty Therapist

Dermatologist

Spa Manager

Clinic Administrator

Medical Aesthetic Practitioner

Skincare Specialist

Compliance Officer

Reception Coordinator

Beauty Salon Owner

Clinical Director

Treatment Coordinator

Industries






Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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