Fraxel Resurfacing Consent Form

FRAXEL RESURFACING CONSULTATION

AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Full Name *

Phone *

Email *

Date of birth *

Medical History

Do you have any allergies? If yes, please specify: *

Are you currently taking any medication? *

Yes

Do you have any history of skin diseases, disorders, or issues? If yes, please specify: *

Are you currently pregnant or nursing? *

Yes

Do you have a history of keloid scarring? *

Yes

Consent and Acknowledgment

In relation to my skin treatment, I have been advised as follows:

Side effects and risks of laser resurfacing

I am 18 years or over.-

I understand that there is no refund for any of the services performed.I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.
I have been informed about the aftercare instructions and commit to following them diligently.
I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.
I understand the costs associated with this procedure and accept full responsibility for these costs.
I certify that I have voluntarily sought the services provided and consent to the treatment.

Signature *

By signing and ticking this, I have read and agree to the clinic procedures of the treatment(s) that I have availed and abide from the instructions.