Name *

First Name

Last Name

Is there any chance of pregnancy? *

Yes

No

Are you breastfeeding? *

Yes

No

Are you allergic to fish? *

Yes

No

The nature of this Procedure, the possible complications and risks, as well as the possible benefits of the Procedure, the alternatives to the Procedure and the risks and benefits for those alternatives have been explained to me in language and using terminology that I understand. My Service Provider has personally answered all of my outstanding questions about the procedure. *

I consent

I fully understand that this Procedure is an elective aesthetic procedure, and that there is no emergency medical condition that requires that I have the Procedure. *

I consent

Neither my Service Provider nor the staff has made any promises or warranties or guarantees as to the success or effectiveness of the Procedure. *

I consent

I understand that the Procedure may not be effective. I have been advised that I may need several treatments for this Procedure to be effective. *

I consent

I understand that after the Procedure, I may experience side effects such as pain, discomfort and tingling, burning, swelling, bruising, Erythema, itching, and swelling, which may be temporary or permanent. *

I consent

I understand that the Procedure is a relatively new procedure and that little is known about its long-term safety and effectiveness. *

I consent

I understand that I will need certain post-Procedure care. I will be dutifully responsible in being strictly compliant with the recommendations from my Service Provider. *

I consent

I must immediately report any unusual symptoms, know to me, to my Service Provider and be especially aware of any slight nature or prominence of persistent chills or fever, redness or increased warmth, excessive bruising or swelling at the site of the injection, fatigue, lethargy, decreased appetite, jaundice {yellowing of skin or the whites of the eyes), dark urine, unusual severe itchiness or abdominal pain. *

I consent

I give my healthcare professional permission to use data about my treatment for research purposes. understand that my name and personal identifying information will remain confidential, unless I give written permission to disclose this information. *

I consent

I hereby authorize having photographs taken of me and that they may be used as an aid in my treatment, in marketing, or study reporting purposes and that any photographs taken will remain the property of the facility. I understand that my identity will be kept strictly confidential. I also understand that these photographs will help document the progress of my treatment and I hereby authorize and consent to the above described photography. *

I consent

Declaration of Consent

I confirm that my treating practitioner has: Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision – Given me the opportunity to ask all remaining questions I may have about the treatment, and has answered them to the best of their ability – Given me the time to consider the treatment detailed overleaf – Received the relevant medical history information from me to the best of my knowledge I therefore consent to receiving the described treatment by my treating practitioner.

By clicking this I consent to receiving the described treatment by my treating practitioner.

Date Signed *

MM

DD

YYYY