General Consent Form for Aesthetic Procedures
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 decreases with time.
In cases involving injections, the amount paid is according to the number of injections and not the final result.
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, and there is an increased probability of bleeding and bruising after the procedure.
I consent to informing my practitioner if at any time my medical condition changes or if I’m taking medications, both topical or oral, especially those such as aspirin, painkillers like ibuprofen, vitamin E, and ginseng, which 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 breastfeeding.
I agree on performing the procedure under the effect 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 and that any amount I paid for the sessions or procedures I booked 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 the 3-month period. I agree that my payment made is non-refundable or non-transferable post this period.
"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 full responsibility for my decision in this consent.
