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Hair Tlansplantation Consent For Smoking and Alcohol

Hair Tlansplantation Consent For Smoking and Alcohol

Patient’s Name:

File No.:

DOB:

Mobile Number:

Visit Date:

Registration Time:

Doctor Name:

Date:

I, visited the for a Hair Transplant procedure.

I was informed about the consequences of smoking / alcohol, which dangerously affect the outcome of procedure, that has a considerable risk on survival of transplanted hair follicles and hence the success of the treatment. I voluntarily go through the procedure and take responsibility.

Sincerly,

Patient Name & Signature :

Doctor/Therapist Name & Signature :

Witness Name & Signature :

Parent or Gaurdian Name (if patient is minor) :

Patient Name & Signature :