Pure

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Age

Gender

Phone Number

Please enter a valid phone number.

Email

example@example.com

GP practice, Address, contact number

Are you happy for us to share details with your GP?

YesNo

Do you have any medical problems?(Asthma,diabetes,heart problem etc ….)

Do you have any autoimmune conditions,cancers,blood disorders,facial problems or skin conditions?(Bells palsy,epilepsy etc …)

Are you currently under the care of a doctor , clinic, hospital or specialist?

Are you taking any medications? If so ,which ones .

Are you Allergic to any thing ?(Medications,latex,pollen etc….)

Are you or could you be pregnant,breastfeeding or Undergoing IVF?

Have you had Covid within the last 2 weeks ?

Have you had a Covid jab in the last 2 weeks ?Due one within 2 weeks ?

Are you due to fly in the next 2 weeks ?

When did you last have any aesthetic treatment and what treatment was it?

I hereby consent to and authorise Pure Medical Aesthetics to perform the following treatment

Treatment

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risk and hazards involved. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risk, and complications. I also recognise there are no guaranteed results and that independent results are dependant upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated area to obtain the expected results at an additional cost.

I have read and understood the post treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. If I may have additional questions or concerns regarding my treatment or suggested home product/post- treatment care, I will consult the clinic immediately. I have also, to the best of my knowledge, given an accurate account of my medical history. including all known allergies or prescription drugs or products I am currently ingesting or using topically. I 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 purpose without my explicit permission. Iunderstand that Pure Medical Aesthetics will not issue a refund for any reason, once the treatment is completed, unless required by statutory law. I have read and fully understand this agreement and all information detailed above. understand the procedure and accept the risk. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Pure Medical Aesthetics, responsible for any of my conditions that were present, but not disclosed at the time of the procedure, which may be affected by the treatment performed today. Pure Medical Aesthetics are committed to ensuring protection of all personal information that we hold, and to provide and to protect all such data. We recognise our obligations to meet the requirements of GDPR.

Client Name

Client Signature

Date

I consent to my photographs being used for marketing purposes on social media and websites connected with Pure Medical Aesthetics and associates. I do not have to consent to this, and it will not affect my treatment in any way. Yes, I am happy for photographs to be used: No, I do not wish for my photographs to be used:

I consent to being contacted for marketing purposes by (please tick preference):

Client Name

Client Signature

Date

Practitioner (All notes must be dated and signed by the practitioner/trainer at time of treatment)

Medication / Products used (attach product sticker)

Prescriber (All notes must be dated and signed by the practitioner/trainer at time of treatment)

Prescriber Name and PIN Number

Practitioner: (All notes must be dated and signed by the practitioner/trainer at time of treatment)

Medication / Products used (attach product sticker)

Prescriber: (All notes must be dated and signed by the practitioner/trainer at time of treatment)

Prescriber Name and PIN Number

Treatment explained?

Skin cleansed?

Aftercare advice given?

Aseptic non touch technique followed where possible?

Practitioner Signature

Practitioner Name

(All notes must be dated and signed by the practitioner/trainer at the time of treatment)

Treatment (by Practitioner)