Consent forms

In order for your treatment to take place, it is important that you complete a consent form as soon as possible to ensure you are suitable for treatment and to avoid disappointment. Once you have booked your appointment, please select and fill in the relevant form below.

PRP Consent Form

IV Infusion Consent Form

Microneedling Consent Form

PRP Consent Form

First name

Last name

Date of Birth

Day

Month

Year

Phone

Address

GP Name, phone number & Address

I give my consent to having my blood taken for the purpose of PRP treatment.

I understand that the risks involved with blood draws include, but are not limited to, discomfort at the site of the blood draw, possible bruising, redness and swelling around the site, bleeding at the sight, feeling of light-headedness when blood is being drawn, and rarely, an infection at the site of the blood draw.

I understand that I am undertaking this treatment knowing the full facts, side effects, treatment outcomes and complications and I will not hold the clinic responsible should any issues mentioned above occur.

I give full consent to the use of my before and after images for marketing purposes, providing all identifying features are covered and that there is no way to identify myself from the image. Images will be kept for 6 years and may be used in the event of a claim being brought against us. They will be stored on a password encrypted hard drive.

Please acknowledge or answer the points and questions: Do you have a history of anaphylactic shock (severe allergic reactions)?

Yes

Do you suffer from any known allergies? If yes, please specify:

Have you had surgery in the last 6 months (including a caesarean section)

Yes

Do you suffer from, or have you ever suffered from Deep Vein Thrombosis

Yes

Are you taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication that can affect platelet function and bleeding time? (You may not be able to receive this treatment)

Yes

Are you taking any dietary supplements such as Omega-3?

Yes

Please state any dietary supplements you are taking.

Do you have or have you had any form of skin cancer?

Yes

Are you taking/receiving steroids, chemotherapy or radiotherapy?

Yes

Have you ever been diagnosed with having HIV, Hepatitis B or Hepatitis C

Yes

I confirm I have no open wounds, skin conditions in the site to be treated.

I can confirm that I have no contagious conditions.

Do you have sensitive skin?

Yes

Are you taking any other medication? If Yes, please specify:

Yes

Please state medications

Do you have diabetes or an immune disease? (you will need a doctors note before receiving this treatment)

Yes

Do you have a heart condition/ Electrical implants or Pacemakers? (You may not be able to receive this treatment) Call the consultant.

Yes

Do you suffer from keloid or hypertrophic scars?

Yes

Have you suffered from or do you have cardiac disease?

Yes

Are you pregnant or is there any possibility that you are pregnant? (You cannot receive this treatment if you are pregnant)

Yes

Have you ever suffered from oedema?

Yes

Will you refrain from intensive sunlight exposure and/or artificial UV exposure for a period of at least 2 weeks?

Yes

Do you suffer from any skin infections?

Yes

I understand that this treatment produces the best possible outcome after a course of 6 treatments within.

I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose.

I understand that treatments and products is not an exact science and I may respond differently to treat compared to others.

I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.

Under GDPR rule I understand that I have full access to all data held on me. This will be held by the clinic for no longer than 6 years for insurance purposes, after which, digital information will be deleted permanently, paper documents will be destroyed. All information on myself is kept on password encrypted file or locked in filing cabinets to which only selective staff members have access. My personal data won't be sold or used for anything other than to provide the services of this clinic.

Microneedling Consent Form

First name

Last name

Date of Birth

Day

Month

Year

Phone

Address

GP Name, phone number & Address

I understand that it is normal for this treatment to cause short term redness, itchiness, tenderness, tightening and or dryness.

Do you suffer from any known allergies? If yes, please specify:

Have you had surgery in the last 6 months? (including a caesarean section)

Yes

Do you suffer from, or have you ever suffered from Deep Vein Thrombosis?

Yes

Are you taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication that can affect platelet function and bleeding time? (You may not be able to receive this treatment)

Yes

Are you taking any medications that cause photosensitivity?

Yes

Are you currently using any topical medications on the area of skin to be treated?

Yes

Have you had any cosmetic surgery on the skin area to be treated in the last 3 months?

Yes

Do you have Haemophilia?

Yes

Have you had Botox or filler on the area to be treated?

Yes

Please state any dietary supplements you are taking.

Do you have or have you had any form of skin cancer?

Yes

Have you ever been diagnosed with having HIV, Hepatitis B or Hepatitis C?

Yes

I can confirm that I have no contagious conditions.

Are you taking/receiving steroids, chemotherapy or radiotherapy?

Yes

Are you taking any other medication? If Yes, please specify:

Yes

Please state medications

Do you have diabetes or an immune disease?

Yes

Do you suffer from keloid or hypertrophic scars?

Yes

Have you suffered from or do you have cardiac disease?

Yes

Are you pregnant, breastfeeding or is there any possibility that you are pregnant? (You cannot receive this treatment if you are pregnant)

Yes

Will you refrain from intensive sunlight exposure and/or artificial UV exposure for a period of at least 2 weeks?

Yes

Do you suffer from any skin infections?

Yes

Do you have any of the following on the area to be treated?

Pustular/Nodular Rosacea

Oedema

Sensitive skin

Acne

Rashes

Psoriasis

Are you taking any medication for acne?

I understand that this treatment produces the best possible outcome after a course of 6 treatments within.

I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose.

I understand that treatments and products is not an exact science and I may respond differently to treat compared to others.

I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.

IV Vitamin Treatment Consent Form

First name

Last name

Date of Birth

Day

Month

Year

Phone

Address

GP Name, phone number & Address

I give my consent to having IV Vitamin infusion treatment.

I understand that the risks involved with IV infusion include, but are not limited to, discomfort at the site of the needle, possible bruising, redness and swelling around the site, bleeding at the sight, and rarely, an infection at the infusion site. And rarely a previously unknown allergic reaction.

Please acknowledge or answer the points and questions: Do you have a history of anaphylactic shock (severe allergic reactions)?

Yes

Do you suffer from any known allergies? If yes, please specify:

Have you had surgery in the last 6 months (including a caesarean section)

Yes

Do you suffer from, or have you ever suffered from Deep Vein Thrombosis

Yes

Are you taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication that can affect platelet function and bleeding time? (You may not be able to receive this treatment)

Yes

Are you taking any dietary supplements such as Omega-3?

Yes

Please state any dietary supplements you are taking.

Are you taking/receiving steroids, chemotherapy or radiotherapy?

Yes

Have you ever been diagnosed with having HIV, Hepatitis B or Hepatitis C

Yes

I can confirm that I have no contagious conditions.

Are you taking any other medication? If Yes, please specify:

Yes

Please state medications

Do you have diabetes or an immune disease? (you will need a doctors note before receiving this treatment)

Yes

Do you have a heart condition? (You may need a doctors note for this treatment) Call the consultant.

Yes

Have you suffered from or do you have cardiac disease?

Yes

Are you pregnant or is there any possibility that you are pregnant? (You cannot receive this treatment if you are pregnant)

Yes

Have you ever suffered from oedema?

Yes

Do you have a liver condition?

Yes

Do you have a Kidney Condition?

Yes

I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose.

I understand that treatments and products is not a precise science and I may respond differently to treat compared to others.

I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved.

Consent Forms

PRP Consent Form

Microneedling Consent Form

IV Vitamin Treatment Consent Form

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