top of page

General Consent Form

Covers consultation, advice, patch tests, and applies alongside all treatments.

Please fill out the following form.

Date of birth
Day
Month
Year

Patient Medical History

Known Allergies (Medications, Latex, Antiseptic)
YES
NO
Autoimmune Disease
YES
NO
Currently Pregnant or Breastfeeding
YES
NO
Diabetes
YES
NO
Current Infection or Illness
YES
NO
Blood Disorder / Clotting Issues
YES
NO
Seizures
YES
NO
High Blood Pressures
YES
NO
Migraines
YES
NO
Skin Conditions (Eczema, Psoriasis, Dermatitis)
YES
NO
Blood Disorder / Clotting Issues
YES
NO
Epilepsy
YES
NO
Heart Conditions
YES
NO
Asthma
YES
NO
Are you currently receiving any Medical Treatment
YES
NO
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.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page