OXYGENEO INFORMED CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

OXYGENEO INFORMED CONSENT FORM

I, understand and agree to undergo the OxyGeneo treatment at . I have been informed of the nature of the treatment, including the steps involved, and I acknowledge that the procedure involves exfoliation, oxygenation, and nourishment of the skin.

I understand that the OxyGeneo treatment is designed to improve skin texture, promote collagen production, and enhance the overall appearance of the skin.


I am aware that, like any cosmetic procedure, the OxyGeneo treatment may have associated risks and side effects. These may include but are not limited to redness, swelling, and potential allergic reactions.


I have disclosed to the practitioner any relevant medical history, including but not limited to allergies, skin conditions, and medications, to ensure that the OxyGeneo treatment is suitable for me.


I understand that alternative treatments and procedures may be available, and I have been given an opportunity to discuss these options with the practitioner.


I acknowledge that the practitioner has answered all my questions regarding the OxyGeneo treatment, and I have been given sufficient information to make an informed decision


I voluntarily consent to undergo the OxyGeneo treatment at Dynamic Aesthetic Clinic, understanding the potential benefits, risks, and alternatives associated with the procedure.


I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period. In case, I decided not to continue with the procedure session(s), the clinic may offer another substitute procedure but is not liable to give the cash refund.


"I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies ".


I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :