Treatment Form

1

Full Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

Town/ City

County

Postcode

Country

3

Contact Number* This field is required.

4

Date of Birth* This field is required.

5

E-mail* This field is required.

6

Preferred method of contact* This field is required.

7

Are you over 18 years of age?* This field is required.

YESNO

8

Are you pregnant or breastfeeding?* This field is required.

YESNO

9

Are you / will you be under the influence of alcohol or illegal drugs at the time of your procedure?* This field is required.

YESNO

10

Do you feel fit and well and able to have your PRX Treatment done?* This field is required.

YESNO

11

I agree to photographs being taken BEFORE, DURING and AFTER my procedure which will be kept in my case file, or used only with my written consent for promotional purposes.* This field is required.

YESNO

12

Do you have any allergies or have you experienced an allergic reaction to medicine or products (such as latex, plaster, nickel etc)?* This field is required.

YESNO

13

Do you have or are you having injectables, fillers or chemical peels?* This field is required.

YESNO

14

Do you have any imminent holiday plans?* This field is required.

YESNO

15

Do you have any keloid scarring?* This field is required.

YESNO

16

Do you suffer from epilepsy and have had a seizure in the last 2 years?* This field is required.

YESNO

17

Do you suffer from Haemophilia?* This field is required.

YESNO

18

Do you knowingly have any infectious diseases?* This field is required.

YESNO

19

Do you knowingly have Hepatitis C?* This field is required.

YESNO

20

Do you suffer from shingles?* This field is required.

YESNO

21

Do you suffer from cold sores, fever blisters or skin disorders in the area to be treated?* This field is required.

YESNO

22

Do you have diabetes?* This field is required.

YESNO

23

Do you have any respiratory problems?* This field is required.

YESNO

24

Do you suffer from or have any problems with wound healing?* This field is required.

YESNO

25

Do you take bloody thinners or anti- inflammatories?* This field is required.

YESNO

26

Do you take Antabuse?* This field is required.

YESNO

27

Do you take Roaccutane?* This field is required.

YESNO

28

Do you have high or low blood pressure?* This field is required.

YESNO

29

Do you wear contact lenses or suffer from glaucoma?* This field is required.

YESNO

30

Are you currently taking any medication?* This field is required.

YESNO

31

Are you 5 weeks pre or post radiotherapy/ chemotherapy treatment?* This field is required.

YESNO

32

Are you allergic to any local anaesthetics? * This field is required.

YESNO

33

I understand that i have chosen a cosmetic procedure that is not medically necessary* This field is required.

YESNO

34

I understand that some results can be cumulative and for optimal effects to be achieved you may be required to return for additional treatments before your overall procedure is deemed complete. The payment for any additional work, if applicable, will be agreed with you prior to your treatment commencing.* This field is required.

YESNO

35

I understand that depending upon the area being treated, additional treatments cannot be performed for 2 - 4 weeks from the date of initial treatment (and sometimes longer). This is in order to allow the area treated initially to fully heal.* This field is required.

YESNO

36

I understand that the skin type of every client is different and the healing process may in rare cases lead to some discolouration of the skin. Skin rejuvenation treatments may therefore be advised after the healing process is complete should this be the case * This field is required.

YESNO

37

I agree that my specialist will document a treatment plan and keep a log of the areas treated, the anaesthetic used, the probe used as well as pre and post treatment photographs. This information will be held securely in my confidential file.* This field is required.

YESNO

38

I understand that after each treatment some swelling or redness may occur which is completely normal. In some rare cases there may be extreme swelling. Your Technician will give you appropriate aftercare advice which must be followed to facilitate your healing and reduce the risk of excess swelling and redness* This field is required.

YESNO

39

I understand that during my treatment i may experience some discomfort depending on the area being treated. Your Technician will reassure you throughout and endeavour to make you feel comfortable and apply more anaesthetic if needed * This field is required.

YESNO

40

I am aware that full aftercare instructions will be provided to me after my treatment and i understand that i must adhere strictly to these instructions.* This field is required.

YESNO

41

I understand that if i do not allow the specialist to complete the procedure then i'm accepting all responsibility for the result.* This field is required.

YESNO

42

Signature* This field is required.I have read and understood this section

Clear

43

I understand the importance of providing accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.* This field is required.

YESNO

44

I understand there are no guarantees as to the success and longevity of my treatment. * This field is required.

YESNO

45

I accept these terms and hereby give my written consent for my trained specialist to carry out the course of treatment of my choice.* This field is required.

YESNO

46

Signature* This field is required.I certify that i have read and i have had explained to me, and fully understand to above consent form and that i have requested to have permanent cosmetic enhancement of my own free will.

Clear

47

Date* This field is required.

Date