Patient Name: Patient Address: Date of Birth: Email Address: Contact Number:
TELEPHONE 01915655556 EMAIL [email protected] WEBSITE http://facialcosmetics.org.uk
Do you suffer from any skin infections (Acne, Herpes)?
Are you taking any medication (contraceptive pill,
Do you have any allergies (including aspirin)?
Are you currently taking any aspirin, steroids?
Are you using a topical Retin A cream or solution?
Are you using any other topical medication?
Do you have any hypertrophic or keloid scarring?
Do you have any allergies or hypersensitivities?
Have you had any previous cosmetic treatment (Dermal
filler, Botox, chemical peel, laser, facial surgery)?
TELEPHONE 01915655556 EMAIL [email protected] WEBSITE http://facialcosmetics.org.uk
I confirm that I consent to receiving treatment using the Lifestyle Aesthetics Peel and Theraderm skin products. I have been given sufficient information to enable me to understand the use of the products for the indications discussed with my practitioner. I have a full understanding of compliance with the therapeutic programme, about the type of topical products used for the purpose of the treatment. I also declare that I have informed my practitioner, without any deliberate omission, of my past and current state of health and about any treatments that I have undergone or am still undergoing, particularly medical-cosmetic treatments. I acknowledge that there can be no guarantee given to the results of the treatment procedure, and that any potential risks and side effects have been explained to me by my practitioner, I have been informed of the following risks, which may include, but are not limited to the following:
Redness and swelling of the skin Stinging, itching, and irritation Dyschromia (hyper/hypo pigmentation) or Scabbing of the treated area, infection. Tightness, prolonged skin sensitivity. I agree not to use any other topical products other that those recommended by my practitioner, during the course of the treatment. I also undertake to inform my practitioner of any unforeseeable reaction that occurs during the treatment phase. I declare that I have understood and therefore accept the terms and modes of the treatment herein, including the nature, purpose, risks and possible consequences of the treatment.
Signed: ____________________________________ Date: _____ / _____ / _________
TELEPHONE 01915655556 EMAIL [email protected] WEBSITE http://facialcosmetics.org.uk
I consent to having photographs taken before and after the treatment.
All photographs will remain the property of Facial Cosmetics Ltd.
Photographs may be used for educational purposes and promotional material. (Delete as appropriate) Signed: ____________________________________ Date: _____ / _____ / _________
TELEPHONE 01915655556 EMAIL [email protected] WEBSITE http://facialcosmetics.org.uk
Hanacpachap cussicuinin .Anon., pub. Juan Pérez Bocanegra in 1631 Juan Pérez Bocanegra, a Spanish-born Franciscan priest, worked in Cuzco in Peru in the early seventeenth century as a missionary. ’Hanacpachap cussicuinin’, a processional hymn in the Quechua language by an anonymous composer, was published in his Ritual in 1631. It is significant as it is the first piece of harmoni
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Willow Creek Dental to use and disclose my protected health information to carry out the following: Treatment (including direct or indirect
Patient Name: