Name *

First Name

Last Name

Is there any chance of pregnancy? *

Yes

No

Are you breastfeeding? *

Yes

No

As with any medical procedure, there maybe risks and side effects, including but not limited to: Redness & Swelling at the injection site, Bruising, Infection, Dryness or flaking of the skin, Allergic reactions, Scar (rare) *

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 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. *

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