ANTIWRINKLE INJECTION CONSENT FORM

Are you feeling well today? YES NO

If female, are you planning to fall pregnant, currently pregnant or breastfeeding?

YES NO

Are you on any antibiotics? YES NO

Since the last treatment, have you been told you have any of the following conditions?

Eaten Lambert Syndrome YES NO

Multiple Sclerosis YES NO

Bleeding disorder YES NO

Since the last treatment, have you had any new allergies?

YES NO

If Yes, please list:

CONSENT:

I, __(Your name) __________________________________________________

Hereby consent to the procedure of anti-wrinkle treatment to be carried out on myself.

I have been informed regarding the treatment and procedure, indications, expected results and possible side effects.

I had the opportunity to discuss all questions answered to my satisfaction.

I have been given and read the patient / client information sheet. YES / NO

I agree that this procedure is being carried out for cosmetic reasons and no guarantee of any nature can be made as the result of the procedure. I accept that while every precaution will be taken to prevent complications and that while complications from the procedure are rare, they can and sometimes do occur.

I am undergoing this treatment of my own free will. I accept responsibility for any complications and thereby absolve anti-aging, Dr Louisa Yim and other associated persons of any blame resulting therefrom.

I will/will not allow photographs to be taken before, during and after treatment for the purpose of educating other patients or for the use in publication provide my identity is protected and my permission obtained.

CLIENT SIGNATURE: DATE: