Consultation Consent Form

Consultation Consent Form

Patient Information for Emerald Clinic London
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information

Please awnser the following accurately.

This will allow your aesthetic doctor to provide you with the safest possible treatment.
Please check the box, if your wander is YES. Leave it empty, if your wander is NO.

Do you have any pre-existing medical conditions?Do you take any medication?Do you suffer from eczema, psoriasis, dermatitis or other skin conditions?Do you have any broken skin on the area being treated?Do you have any allergies?Do you suffer from frequent eye irritation, itching or watery eyes?Are you pregnant or breastfeeding?Do you suffer from epilepsy or any seizures?Have you had any recent trauma, surgery?Do you have a history of cold sores (Herbes Simplex)?
If you answered yes to any of the above, please elaborate here, including frequency and any treatments used:
Do you give permission for your photographs (with no name or identifying details) to be used for educational or promotional purposes (e.g. website, social-media)?

Yes
Please check the box:

I confirm that the procedure has been fully explained to me by a qualified specialist.I have had the opportunity to ask questions, and all of my concerns have been addressed.I am giving my full and informed consent to proceed with the treatment.
Signature

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Signed Date

MonthDayYear
Date
Should be Empty: