<%@ Page Language="C#" AutoEventWireup="true" CodeBehind="pinkmood_consent_for_Fibroblast.aspx.cs" Inherits="WebMediSmart.consentform.orthodontic_treatment" %> Mesotherapy/Stem Cells For Hair Consent

MESOTHERAPY/ STEM CELLS FOR HAIR CONSENT FORM

I hereby consent to Mesotherapy/ Stem Cells treatment for hair fall.

I understand that this treatment results in decreasing the number of the shading hair. It helps other medical treatments to stimulate hair growth. This depends mainly on the quality of the hair follicle.
Good results are only obtained in the absence of hormonal imbalances.
There is no pain associated with the treatment. And it is advised to avoid washing the hair after the session for 1 days.
I know that this treatment requires 4 – 8 sessions with 1 – 4 weeks intervals.
I understand that the degree of improvement depends on the response of my hair to the treatment. And that there might be a need for combination therapy with other procedures to obtain the desired result.
I must inform the doctor about any illnesses that I have and about any medications that I am taking during the treatment or for 2 weeks prior to the treatment.
I confirm that I read and understood the above information. And that I will follow these instructions, or any other instructions given by the doctor. And I admit that the doctor explained to me the steps and the consequences of the treatment, and the time required for it. I hereby authorize him to carry out Mesotherapy for hair.

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