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Hair Treatment Consent Form

Please fill out the following form.

Date of birth
Day
Month
Year

Patient Medical History

Currently Pregnant or Breastfeeding
YES
NO
Autoimmune Disease
YES
NO
High Blood Pressure
YES
NO
Diabetes
YES
NO
Skin Conditions (Eczema, Psoriasis, Dermatitis)
YES
NO
Known Allergies (Medications, Latex, Antiseptic)
YES
NO
Blood Disorder / Clotting Issues
YES
NO
Heart Conditions
YES
NO
Current Infection or Illness
YES
NO
Seizures
YES
NO
Epilepsy
YES
NO
Asthma
YES
NO
Migraines
YES
NO
Are you currently receiving any medical treatment
YES
NO
Please select the treatment you are coming in for

Hair-Specific History

Scalp Infection or Inflammation
YES
NO
Bleeding Disorders
YES
NO
Recent Hair Transplant
YES
NO
Autoimmune Conditions
YES
NO
Blood Thinning Medication
YES
NO

PRP / Injectable Hair Disclaimer

I understand Multiple Session may be required
YES
NO
I understand Results vary and take time
YES
NO
I understand Temporary Shedding may occur
YES
NO

Anesthetic Disclaimer (If Microneedling Used)

I have Allergy to Anesthetic
YES
NO

Consent Declaration

I Confirm that the Information provided is Accurate
YES
NO
I Consent to Images / Videos being taken for Medical Records
YES
NO
I Consent to Anonymized Marketing use of Images / Videos
YES
NO
I Consent to Treatment following Consultation
YES
NO

The clinic shall not be held liable for treatment outcomes or perceived treatment failure where procedures have been carried out appropriately and in accordance with accepted professional practice and aftercare guidance.

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