The following is to confirm that we have discussed with you the nature of your condition,
the proposed treatment thereof, the prospects for success and the limited risk of
potential side effects associated with such treatment. As per current medical knowledge
any potential side effects resulting from our treatment are reversible and temporary in
nature.
By signing this form, you confirm and consent to the following:
My medical condition and the proposed treatment have been explained to me. I have
been advised that although good results are expected, the possibility and the nature of
complications cannot be accurately anticipated and therefore, there can be no guarantee,
either expressed or implied as to the success or other result of treatment, and that the
effect of some procedures like fillers and Botox injections decrease with time.
In case involving injections, the amount paid according to the number of injects and not
the final result.
Patient’s response to the treatment varies from one person to another and some may
not respond.
The potential side effects of the treatment may include but are not limited to bruising,
temporary pain and itching, redness, infection, bleeding, onset of viral or bacterial
infection, facial nerve affection, unsatisfactory cosmetic result, extrusion, onset of acne,
burning and blistering, fat necrosis, hyper/hypopigmentation, numbness, swelling,
asymmetry, transient skin discoloration, and or allergic reaction. There might also be
reversible brow or eyelid ptosis or muscle weakness throughout the body with Botox.
Blindness could occur in rare cases an increased probability of bleeding and bruising after
the procedure.
I consent to informing my practitioner if at any time my medical condition changes of if
I’m taking medications both topical or oral, especially that some medications like aspirin
and pain killers like ibuprofen, vit e, and ginseng could cause an increased probability of
bleeding and bruising after the procedure.
I have consulted with the practitioner who will be treating me and all my questions
concerning the treatment have been answered to my satisfaction.
I have informed the doctor that I’m not currently pregnant or breastfeeding in case the
procedure has an effect on pregnancy or breast feeding.
I agree on performing the procedure under the effect t of local anesthetic in the form of
topical cream or injection.
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 by
while .
I further authorize that the photographs may be published for any purpose and in any
form.