Patient Treatment Consent Form

Treatment Consent Form-VC

Injectables, Peels & Fillers
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Phone Number*
Email
example@example.com
Date Of Birth

MonthDayYear
Date
Check the conditions that apply to you:*

Facial PalsyHeart DiseaseHigh Blood PressureConvulsionsHepatitisRheumatoid ArthritisEpilepsyPsychiatric DisordersDepressionBlood Clotting DisordersDiabetesBleeding DisordersSkin DiseasesNeuromuscular DiseaseCold SoresPregnantBreastfeedingAllergiesPlastic SurgerySkin CancerMajor SurgeryDental SurgeryLow Blood PressureKeloid or Hypertrophic ScarringNone of the above
If you have ticked any of the above please explain here
Have you received or had any of the following?*

Previously had Botulinum Toxin or Anti Wrinkle treatmentDermal FillersImplantsLaser skin resurfacingSkin peelsAnaphylactic shockNeedle phobiaSusceptibility to bruisingSun bed treatment recentlyAcne treatment recentlyNone of the above
Are you currently taking any medication including steroids or anti-biotics?*

YesNo
If Yes, what medication are you taking?
Do you have any medication allergies?*

YesNoNot Sure
If Yes, what?
Photographic images - Images will be taken pre and post procedure which we will store securely. However, we would like your consent to use these results further on our website, advertising and marketing materials, you will not personally be identified from the photos.*

I consentI do not consent
Signature

Clear
Should be Empty: