CONSENT FORM

NAME:

ADDRESS: DOB:

TELEPHONE:

HAVE YOU HAD ANTIWRINKLE INJECTIONS PREVIOUSLY? YES NO

If yes, which type?

ARE YOU PREGNANT OR BREASTFEEDING? YES NO

ARE YOU PLANNING TO FALL PREGNANT? YES NO

ARE YOU TAKING ANY ANTIBIOTICS? YES NO

DO YOU HAVE ANY CHRONIC MEDICAL CONDITIONS? YES NO

(e.g. NERVE RELATED DISORDER/DIABETES/BLEEDING DISORDER)

If yes, please list:

DO YOU HAVE ANY ALLERGIES? YES NO

PLEASE LIST:

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:

DR LOUISA YIMÕS SIGNATURE: DATE: