Derma Fillers Questionnaire Consent Form and Record Declaration

Aesthetics Consent Form and Record Declaration
by the Aesthetic Therapist providing treatment

Declaration by the Therapist providing treatment

I am appropriately trained, insured and have suitable experience to provide this treatment. I have explained the intended benefits of the treatment to the client along with its limitations and any possible risk. I have discussed treatment alternatives, including not having the treatment. I have afforded ample opportunity to read and understand the written information provided, which also includes post-treatment advice.

I have discussed with the client in detail about what the procedure involves, and explained that the client may withdraw consent to treatment at any time.
Name:
Signature
Date:

MonthDayYear
Date
Declaration by the client receiving treatment

I have received sufficient information about the aesthetic treatment I am to receive and read the information sheet about this procedure. I have detailed explanation of the procedure I am to undergo. I fully understand the aims and objectives of the treatment. I am aware of the limitations, possible risks and unexpected side effects that may not be possibly anticipated beforehand; as well as the intended benefit to my appearance and wellbeing. I also understand the usual possible range of variation in the expected outcome of the treatment, which has been explained to me by the practitioner performing the treatment- procedure. I understand that the local anaesthetic may be applied or injected. I have had further opportunity to consult a medically qualified professional and have all my questions answered to my entire satisfaction. Having considered all aspects, I have decided to have this treatment of my own accord with sole intention the anticipated benefit from the same, provided by the practitioner performing the treatment procedure. I understand that I will not be able to sue my therapist in case of any complications or be entitled to a refund if I am not happy with my procedure. I agree to follow the post treatment advice provided. I hereby consent to receive the treatment described herein. I further consent to be photographed before, during and after treatment. I understand that these photographs would remain the property of the professional practice and will not be used for marketing purposes without my explicit permission. I understand my right to withdraw consent at any time.
Name:
Signature
Date:

MonthDayYear
Date
Derma Fillers Questionnaire Consent Form and Record
Aesthetic Therapist
Name:
Address:
D.O.B:
Gender:
email:
example@example.com
Postcode:
Tel:
Mobile:
Reason for having
HEALTH QUESTIONNAIRE
PLEASE TICK THE BOX IF ANY OF THESE APPLY TO YOU
Are you pregnant/breastfeeding
Do you have tendency to Keloid/excessive scarring?
If you answered YES to any of the above questions, please provide further information If you are contra indicated, you may be referred to your GP, your treatment may be referred or refused
Name:
Signature
Date:

MonthDayYear
Date
Age:
Should be Empty:

Aesthetics Consent Form and Record Declaration

Derma Fillers Questionnaire Consent Form and Record

HEALTH QUESTIONNAIRE

PLEASE TICK THE BOX IF ANY OF THESE APPLY TO YOU