Aesthetics Consent Form

First Name: *

Surname: *

D.O.B *

Address: *

Telephone: *

Email: *

Doctor's Name: *

Doctor's Address:

Doctor's Phone:

Major Contraindications (tick any that apply):

Pregnancy Auto-immune disease Cancer "Roaccutane" Grade 4 Acne Diabetes Impetigo

DO NOT PROCEED IF ANY SELECTED

Minor Contraindications (tick any that apply)

Eye Infections e.g. Conjunctivitis / Styes/Hordolea / Cysts Skin Disorders e.g. Active Acne / Seborrheic Dermatitis Herpes Simplex (cold sores) / Eczema / Psoriasis / Rosacea Keloid Scars Telangiectasia (broken capillaries) Raised Moles / Warts / Skin Tags Cuts / Bruises / Abrasions

Proceed with caution - avoid affected areas.

Are you taking any medication at the moment? If so, what? *

Yes No

If so, what?

Have you had Botox/dermal fillers? If so, when? *

Yes No

If so, when?

Have you had any another aesthetic treatments? *

Yes No

Botulinum Toxin, Dermal Fillers, Dermal Roller, Dermaplaning, Semi/Permanent Makeup

If so, when?

Do you suffer from epilepsy? *

Yes No

I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.

I have been advised: No AHAs, Glycolics, Retinol, Anti-Ageing products or exfoliating products for 72 hours. No sauna, sun bed or sun exposure for 48 hours. No swimming, facial waxing, electrolysis or fake tan application for 24 hours. No heavy make up for 12 hours. Use of SPF15 at all times during the course of treatment is strongly recommended.

Please read carefully and only sign if you are in full agreement with its contents. I confirm that I have understood the treatment that I am about to receive and confirm that I am willing to proceed without confirmation from my own GP or consultant.

Signed:

Signed: *

Tap or click on the signature above to sign

You should note that if the therapist is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or consultant.

It is your responsibility and not that of the therapist to consult your GP or consultant. By signing this form you are hereby indemnifying the therapist against any adverse reaction sustained as a result of the treatment.

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.