Milia Removal Consent Form

Milia Removal Consent Form
Name

First NameLast Name
Address

Street Address

City
Date of Birth

MonthDayYear
Date
Email
example@example.com
Medical History
Do you have any Medical issues or Chronic illness
Do you take any Medications or Supplements?
Do you have any Allergies?
Do you have any Skin Sensitivies?
What Skincare are you currently using?
I understand that I will receive Milia Removal by way of the deroofing proceedure, although there is minimal trauma to the skin, I understand there is a small risk of the following;

1. Scarring and Post Inflammatory Pigmentation (PIH), changing of the skin colour either ighter or darker

2. Infection

3. Post care procedures are necessary and requires my cooperation.

4. There is no guarantee of results of any treatment, you may need to come back for further treatments

5. The Nurse can reserve the right to not treat you if they feel it will compromise your skin further or you are not a suitable candidates for treatment and may refer you back to your GP or a Dermatologist.

6. You will be a charge of $25 for a skin consultation if the Nurse decides to not treat you as it may compromise your skin or you are not suitable for treatment or the lesions are not milia.

7. You will be charged $120 for milia removal treatment.
Signature

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Date

MonthDayYear
Date
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