SKIN LIGHTENING AND BRIGHTENING  - Vitamin Treatment Medical Consent form
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IMPORTANT INFORMATION ABOUT VITAMIN TREATMENTS
IM injections and IV drips are prescription only medicines and have to be ordered at least ONE WEEK PRIOR TO TREATMENT.You have to fill in this medical consent forms and pay for your treatment(s), (single treatments, or the full course) and book in order for us to process your prescription. Thank you for your co-operation in this.

Skin lightening and brightening vitamin treatment

Contains vitamin C - Powerful antioxidant

PLUS Glutathione - Although not a vitamin Glutathione is a very powerful antioxidant, neutralising free radicals.

Side effects and risks can be:

Cramping
Bloating
Rash


Treatment time 30 minutes to one hour


PLEASE COMPLETE THE FOLLOWING
Please select the treatment(s) and method *
Full name *
Address (number and street name) *
Town *
County *
Postcode *
Country *
Contact telephone - landline *
Contact telephone - mobile *
Email address *
Date of birth *
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Doctors name *
Doctors address including postcode *
Medical history - please select all applicable *
Required
For any items ticked above please can you provide full details including medications (blood pressure please state if high or low, please state type of autoimmune disease and the type for diabetes). Type N/A if you have none of the above. *
Please confirm if you have had any of the following treatments *
Required
If you have had any of the treatments above please complete below the make, treatment area, when you last had treatment and any adverse reaction if experienced. Type N/A if you have not. *
Allergies *
Required
Client Consent and Declaration Form for Treatment
The information I have given is correct to the best of my knowledge. I have not knowingly withheld any medical or surgical information. I agree to inform my practitioner of any health or medication in the future. I have discussed the above with my practitioner and agree to treatment. I have been given sufficient time to consider the information, risk and likely outcomes of the proposed treatment. I can withdraw my consent in writing to treatment up to and after the start of treatment providing it is safe and practical to stop treatment. I have read and understood the notes on Chaelis Aesthetics Clinic’s obligations under the Data Protection act 1998 and GPDR as of 25th May 2018. I have read and understood the risks and expectations as described by my practitioner. I have been fully informed of the nature and purpose of the procedure.  I understand and fully accept the use of lidocaine, should it be necessary by injection or topical application for pain management and I am aware the risk of reaction is possible. I have been given the opportunity to ask questions and where I have asked questions they have been answered to my satisfaction. I have received any pre and post care instructions where necessary, and I agree to follow such instructions. I understand it may be detrimental to my health and the treatment not to follow instructions. I shall report any worries or side effects to my practitioner within three to four days. I understand there are no guarantees or assurances as to the final result that may be obtained and that any issues that need to be addressed or rectified will be done within reasonable time and there may be a charge for this. If necessary the use of topical anaesthetic cream. If necessary Lidocaine injections. Anonymised before/after photos for insurance and/or promotional purposes (If this box is unticked to the question of photographs, we will be UNABLE to offer treatment.) For my GP to be contacted and information shared in an emergency. For my next of kin to be contacted and information to be shared in an emergency. By submitting these forms you agree that all the information is true and accurate *
Required
PLEASE BE AWARE THAT  SIGNING THESE FORMS AND/OR MAKING AN APPOINTMENT OBLIGES YOU TO BE IN AGREEMENT WITH THE TERMS AND CONDITIONS HERE IN.
Chaelis Aesthetics Clinic aims to keep its very competitive prices. Cancellations and, “no-shows” take up valuable clinic time and we therefore operate a strict appointment policy. All treatments must be paid for at time of booking. Clients have a seven day cooling off period. If you cancel 24 hours before your appointment, or fail to show for your appointment, you will be charged 100% of your treatment. If you cancel 48 hours before your appointment you will be charged 50% of your treatment. Late arrival may result in forfeiting your appointment: we do not offer compensation for this. We regret that due to the nature of the clinic we cannot admit children to the premises. *
Required
COVID-19 PANDEMIC IMPORTANT INFORMATION AND CONSENT
During this time, we have had to adopt various protocols and introduce new consultation documents in an attempt to stop the spread of the virus, in accordance with best practice and government guidelines. We are also limiting the areas of touch inside the clinic in order to protect our clients as much as possible. If prior, or on the day of your appointment, you have had any of the following symptoms please call the clinic to re-arrange after 14 days isolation: Fever, Shortness of breath, Loss of taste or smell, Dry cough, Runny nose, Sore throat, Conjunctivitis. Payment must be made in full at least 48 hours prior to your appointment. Please ring the clinic with you card details. Please bring a bottle of water with you and take it home with you afterwards. We cannot offer any beverages to clients. Please visit a toilet before you arrive at the clinic as our facilities are closed. Please do not wear any jewellery, other than a wedding ring. Earrings, bangles, bracelets, necklaces and other rings cannot be allowed. Please leave all outerwear, bags and mobile phones in your car. They are not allowed in the clinic. Please arrive only at the time of your appointment as we are trying to limit the contact between clients. Please do not bring friends, relatives or children to the clinic. We can only admit the client for treatment. When you arrive at the clinic: We will check your temperature with a remote thermometer. You must wash and sanitise your hands. You must wear the PPE given to you. You will be required to wear a mobcap, mask, shoe-covers and a coverall. New client consultation. We have to consider the risks to our clients, and to ourselves and the populace in general. To facilitate this, we are carrying out new client consultations by appointment on Zoom, Facetime, whatsapp video or FB Messenger video. Please ring for an appointment. This consultation will be “fine-tuned” at your treatment appointment. I have read and understood the above and agree to abide by the statements made. *
Required
Release Form and GPDR Consent
I certify that the consultation statements I have given are true and correct and that I, having been advised by Lesley Spencer completely understand the implications of the treatment I will be receiving including the listed side effects and at no time have I been mislead or badly informed by the above mentioned practitioner or company. Any falsifications of information submitted by myself could be detrimental to my health and success of my treatment and may cause me to experience possible discomfort. I hereby authorize and direct the company and the practitioner to administer the prescribed process and perform such procedures as may be deemed necessary and advisable. My signature below constitutes my acknowledgement that (1) I have read, understood and fully agree to the forgoing. I further understand that I have a seven day cooling off period.(2) give consent to the proposed treatment process that has been satisfactorily explained to me and I have all the information I desire (3) give my consent and authorization voluntarily and release the establishment and it’s agents of any claims that I have or may have in the future in connection with the treatment. (4) I understand that the results may not be up to my expectations. (5) I understand that more than one treatment may be necessary. (6) I have received, read and understood pre and post care instructions. (7) We take your privacy seriously. We will only use your personal information to provide you with aesthetic care related services, including appointment, recording and processing your information relevant to your aesthetic treatment and care and medical conditions. Where necessary we may share your information with third parties such as your doctor and the NHS and your next-of-kin. Additionally we may also contact you with details of other details and services we provide. Please select your preferred method of contact. *
Required
By submitting these forms you agree that all the information is true and accurate *
Required
Signature (please add your name to act as your signature) *
Date *
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