<%@ Page Language="C#" AutoEventWireup="true" CodeBehind="pinkmood_consent_for_Fibroblast.aspx.cs" Inherits="WebMediSmart.consentform.orthodontic_treatment" %> Facial Consent

FACIAL CONSENT FORM

I hereby consent to a facial treatment; tthese procedures are results orientated and are designed to change and improve skin conditions.

Each person’s experience will be different and you may experience:

Break-outs, congestion and trapped sebum plugs may be released, resulting in a superficial break out.
Dry, tight patches – this is where dead protein cells are still attached to the epidermis and has not been released.
Underlying pigment due to the aging process, may appear darker.
Your skin may experience temporary irritation, tightness, or redness.
You may experience tingling and stinging in the treatment area.
Client experiences may vary.
You will likely see results immediately after treatment and your skin may feel smooth and hydrated
Avoid excessive sun exposure and use a SPF sunscreen.
I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.
Any contraindications will void this offer and treatment
This treatment cannot be transferred to another person
Once the machine has been turned on, refunds are prohibited
Appointments preferences are based on machines availability

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

Pre and post treatment instructions have been explained to me.
I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
I must notify the clinician if my medical history changes prior to subsequent treatments.
I consent to clinical photographs being taken of my treated areas for my personal health record only.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE CLINIC, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature