FILLER ON VULVA-VAGINAL MUCOSA CONSENT FORM

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

FILLER ON VULVA-VAGINAL MUCOSA



I,the undersigned Mrs / Ms authorize to perform filler on vulvo-vaginal mucosa / area,

on me. I declare to have received from detailed explanations about the treatment.

Mentioned above and all necessary material for a complete and comprehensive understanding of the filler procedure which I will be subjected. I also declare that I have been able to discuss these explanations, to have asked all the questions that I felt were necessary and to have been given satisfactory answers, as well as having had the opportunity to enquire about the details of the procedure with a person I trust.

In particular, I declare to have been made aware in a simple and clear language about:

a. the type of intervention.
b. the risks related to the intervention itself, as well those related to anesthesia.
c. any possible complications.
d. the postoperative course.
e. alternative therapies.
f. results may vary from patient to patient, as well as satisfaction of the results.

I also understand that not adhering to the post care instructions provided to me by the Doctor may increase my chance of complications.

Therefore, agrees to undergo the proposed filler 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.

"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 :