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 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 :