CLIENT CONSENT FORM Full Name Email Address Date of Birth Mobile Number Address inc. Postcode Previous Next 1) DO YOU HAVE ANY MEDICAL PROBLEMS? YesNo Please provide details 2) DO YOU HAVE ANY AUTOIMMUNE, BLOOD, NERVE, SKIN, OR MUSCLE CONDITIONS? YesNo Please provide details 3) ARE YOU CURRENTLY UNDER THE CARE OF A DOCTOR, CLINIC, HOSPITAL OR MEDICAL SPECIALIST? YesNo Please provide details 4) ARE YOU TAKING ANY MEDICATIONS? YesNo Please provide details 5) ARE YOU ALLERGIC TO ANYTHING? (MEDICATIONS, LATEX, NEEDLES ETC.)? YesNo Please provide details 6) ARE OR COULD YOU BE PREGNANT, BREASTFEEDING OR UNDERGOING IVF? YesNo Please provide details 7) Have you had anti-wrinkle treatments before? YesNo Please provide details Previous Next DECLARATION OF CONSENT I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about: The risks specific to me The risks inherent in the procedure The expected benefits of the treatment The risks inherent in refusing the procedure The potential disadvantages of the treatment The aims/motivations for having the procedure and the desired outcome Any uncertainties about and the likelihood of success of the procedure Alternative procedures and their pros and cons including the option of no treatment at all Any follow-up treatment that may be required I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision. I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures. I consent to before & after photos for my client records. I also consent to these images being shared on estara’s social media channels. CLIENT SIGNATURE Clear Previous Next
