Treatment Consent Form
Clinic Use Only
Client Name
First Name
Last Name
Client Email
example@example.com
Any concerns from practitioner or client that were discussed
Client Date of Birth
-
Month
-
Day
Year
Date
Your Areas of Concern
Please tell us what areas of concern you have
Please indicate areas of concern:
*
Forehead
Frown Lines
Freckles & Pigmentation
Crow's Feet
Dark Circles
Blood vessels
Nasolabial Folds
Scarring
Vertical Lip Lines
Oral Commisures
Lips: Definition and/or fullness
Large Pores, Poor Skin Texture & Fine Lines
Marionette Lines (Mouth-to-Chin Lines)
Hair Loss
Vitamin Deficiency
Better Wellbeing and Energy
Wrinkled Neck
Crepey Chest and Neck
Fat Reduction
Wrinkled Hands
Stomach
I have read and consent to the treatment I have booked at Perfect Angle Medical Aesthetics
*
Consent for Promotional Use
Internal Use Prior to Treatment
Name
*
First Name
Last Name
Heading
PERMISSION TO TAKE & USE PHOTOGRAPHS OR VIDEOS TAKEN DURING TREATMENT
I grant to Perfect Angle Medical Aesthetics the right to take photographs and/or videos of me immediately prior to, during, and/or after my treatment. I authorise Perfect Angle to copyright, use and publish the same in print and/or electronically. I agree that Perfect Angle may use such photographs and/or videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.
*
Yes
No
Signature
*
Date
*
.
Month
.
Day
Year
Date
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Clinic Use Only
To be completed by a medic only
Notes
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