Patient Details

First Name *

Last Name *

Phone *

Email *

Medical Information

Allergies *

Underlying Health Conditions *

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Consent & Acknowledgements

Procedure Understanding: I acknowledge that the procedure(s) I am undergoing have been explained to me in detail by Faiza. I understand the purpose, the potential risks, and the expected results.
Potential Risks: I understand that all procedures carry certain inherent risks.
Alternative Treatments: I am aware of alternative treatments available, even if not offered at Aesthetics by Faiza.
No Guaranteed Outcomes: Individual results may vary, and the desired outcome is not guaranteed.
Follow-Up and Aftercare: I commit to following all aftercare instructions provided by Faiza and understand the importance of post-treatment check-ups or reviews.
Release of Liability: I release "Aesthetics by Faiza", Faiza, and any associated staff from any and all liability associated with the procedure(s).
Emergency Medical Treatment: I grant permission for emergency medical treatment by the clinic, its staff, or its representatives, in case of an adverse reaction.
Data Protection and Privacy: I understand how my data will be used and stored by "Aesthetics by Faiza" in compliance with GDPR regulations.
Cancellation and Refunds: I am aware of the cancellation and refund policy of "Aesthetics by Faiza".
Duration of Consent: This consent is valid for the duration of my treatment series or one year, whichever is shorter.
Understanding & Questions: I acknowledge that I have had the opportunity to ask questions regarding the procedure(s), and all my questions have been answered to my satisfaction.
Consent to Procedure: I voluntarily request and give my permission to "Aesthetics by Faiza" to perform the aesthetic procedure(s) on me.

Photo Release *

I consent to the use of my before and after photos for educational or promotional purposes.

I do not consent.

Date *

Customer Signature *

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