Accent RF Patient Consultation Form

Client Name: *

Date: *

Date of Birth: *

Email: *

Address: *

Postcode: *

Home Phone:

Mobile: *

How would you like us to contact you? *

Text Email

Medical History

Please complete the following medical questionnaire:

Are you taking any medication? *

Yes No

Do you have any allergies? *

Yes No

Have you a history of severe allergy / anaphylaxis? *

Yes No

Pregnancy (ies) (previous and current)? *

Yes No

Are you currently receiving medical treatment? *

Yes No

Have you had any recent operations/scar tissue? *

Yes No

Do you have any tumors, abnormal swelling or lymph oedema? *

Yes No

Do you have any heart/cardiac disorders: *

Yes No

Do you have Thrombosis/Phlebitis (blood clots)? *

Yes No

Do you have a Pacemaker or internal metal pins? *

Yes No

Is there a personal/family history of skin cancer? *

Yes No

Do you have epilepsy? *

Yes No

Recent exposure to UV light? *

Yes No

History of keloid scarring? *

Yes No

Fragile or exceptionally dry skin? *

Yes No

Do you suffer from Herpes Simplex 2 (cold sores) (Facial)? *

Yes No

Have you recently had Botox/Collagen/injectables? *

Yes No

Do you take any form of contraception/hormonal substitutive? *

Yes No

Do you have any skin diseases or disorders? *

Yes No

Do you have Underactive/Overactive Thyroid? *

Yes No

Do you have Psoriasis (in treatment area)? *

Yes No

Regular Menstrual Cycle? *

Yes No

If you have answered Yes to any of the above, please provide more detail:

Please inform your Clinician about any other medical conditions.

Treatment Consent:

I confirm that I have received a full Consultation with regards to the proposed Accent Radio Frequency treatment and would agree that is has been explained to me fully. I am aware of the possible side affects and agree to follow both the pre and post care to minimalize the risk of any adverse reaction.

I agree to advise the clinic/salon of any changes in personal medical circumstances.

I understand that after treatment, there will be heat in the area and some redness. In rare cases oedema and blistering can occur. This is a normal side effect of treatment and will settle within days. Instructions have been given regarding aftercare and I agree to follow these instructions and to inform the clinic of any condition that causes concern immediately.

I understand that I may require more than one treatment to achieve the desired results. This has been fully explained to me and I am aware the results of the treatment may vary.

I hereby certify that I have been fully informed of the nature of the procedure, expected outcome and possible complications. I understand that there can be no guarantee or assurance as to the final result that may be obtained. I consent to the taking of photographs and authorize their anonymous use for the purpose of medical audit, education and promotion. I am aware that my condition is primarily of cosmetic concern and that the decision to proceed is based solely on my express wish to do so. I have been given the opportunity to ask questions and hereby certify that I have read and fully understand the contents of this consent form.

Client signature: *

Tap or click on the signature above to sign

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.

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