Skin Booster Consent Form

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

Skin Booster Consent Form:

I understand that the skin booster treatment aims to improve skin hydration, texture, and overall appearance.

I am aware that the skin booster treatment may have potential risks and side effects, including but not limited to redness.

• Swelling
• Bruising
• Infection
• allergic reactions
• or other complications

I, have been informed about alternative treatments or procedures that could achieve similar results, and I understand why the skin booster treatment is being recommended.

I agree to follow all pre- and post-treatment instructions provided by the Dr. I will promptly report any unusual symptoms or complications to the medical facility.

I have been given the opportunity to ask questions and seek clarification about the skin booster treatment, its potential risks, benefits, and alternatives. I understand the information provided and consent to undergo the procedure.

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.

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 :