HYALURONIDASE TREATMENT CONSENT FORM


Patient’s Name:
File No.:
DOB:
Mobile Number:
Doctor Name:
Visit Date:

  1. I, hereby acknowledge that i have requested and voluntarily consent to a hyaluronidase treatment from Beauty Wise Medical Centre.
  2. I understand that no guarantee can be made as to the result of the treatment and the hyaluronidase use for filler corrections is an off-label non-approved one.

I confirm that in order to undergo the said treatment, I accept the following conditions:

  1. Beauty Wise Medical Center and medical staff cannot be responsible for any results of treatment from any other physician or service provider.
  2. I will not hold Beauty Wise Medical Center or Dr. or medical staff legally or financially responsible for anything resulting from the treatment that I deem unsatisfactory. I will not hold Dr. or Beauty Wise Medical Center financially or legally responsible for any current or prior treatment.
  3. I acknowledge and accept that Beauty Wise Medical Center, Dr. and associated medical providers has informed me fully that results are not guaranteed and vary from person to person.
  4. I acknowledge that Beauty Wise Medical Center and associated medical providers have explained the procedure in detail during consultation and has made me fully aware of all the possible outcomes and/or side efforts (brusing, swelling, pain, allergic reactions of lumpiness or irregularity in the contour of the treated area and or textual changes to the skin that may last for few weeks). And that may alternative is to do nothing or seek other forms of treatment from other providers.
  5. I understand and accept the above and enter into this agreement willingly and voluntarily. I understand that any treatment provided may or may not meet my expectations.
  6. I understand and agree that there is no compensation or refund of monitory paid in any event.

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :