Skin Enhancement Consent Form

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

Skin Enhancement Consent Form

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 decrease with time.

• In case involving injections, the amount paid according to the number of injects and not the final result.

•Patient’s response to the treatment varies from one person to another and some may not respond.

•The potential side effects of the treatment may include but are not limited to bruising, temporary pain and itching, redness, infection, unsatisfactory cosmetic result, extrusion, onset of acne, burning and blistering, fat, hyper/hypopigmentation, numbness, swelling, transient skin discoloration, and or allergic reaction.

• I consent to informing my practitioner if at any time my medical condition changes of if I’m taking medications both topical or oral, especially that some medications like aspirin and pain killers like ibuprofen, vit e, and ginseng 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 breast feeding.

• I agree on performing the procedure under the effect t 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 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 :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :