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Injectables Consent Form

Please fill out the following form.

Date of birth
Day
Month
Year

Patient Medical History

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

Additional Medical History

Allergy to Lidocaine or Local Anesthetics
Yes
No
Active Cold Sore / Herpes Simplex
Yes
No
Previous Adverse reaction to Injectables
Yes
No
Blood-thinning Medication (Aspirin, Warfarin, etc.)
Yes
No
Immune-Suppressing Medication
Yes
No
Recent Dental Work (Last 2 weeks)
Yes
No
Previous Filler Complications
Yes
No

Lidocaine / Anaesthetic Disclaimer (MANDATORY)

I Confirm i have no known allergy to Lidocaine or Topical Anesthetics
Yes
No
I understand Anesthetic products may cause rare allergic reactions
Yes
No

Risks Acknowledgement

Bruising, Swelling, Redness
Yes
No
Vascular Occlusion (Rare)
Yes
No
Infection
Yes
No
Temporary or Permanent Complications
Yes
No
Asymmetry
Yes
No

Consent Declaration

I Confirm that the information Provided is Accurate
Yes
No
I Confirm to Images/Videos being taken for Medical Records
Yes
No
I Confirm to Treatment following Consultation
Yes
No
I Confirm to Anonymized Marketing use of Images/Videos
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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