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Sample Consent Form

Consent form

Areton Ltd presents this document as a template for the convenience of its customers only and not any other party. It is strongly recommended you consult your insurer and your legal consultants before using this document (amendments may be required). Areton Limited does not assume any responsibility for any inclusions, mistakes or omissions within this document. It is advised to keep a signed copy for your record and one should be handed out to the client.

Sample Consent Form

Client Name: ……………………………………….

Email Address………………………………………

Mobile Number…………………………………….

Date: …………………………………………………..

I confirm that I am over 18 and under 65 and that I have been advised of the following:

  • The ‘BeautyTeck’ is an aesthetic device. This device is not intended to treat any disease or medical condition. Only benign skin lesions removal can be carried out for aesthetic reasons only. The aesthetic practitioner may not be able to make any diagnosis or assessment of the skin lesion, you intend to have removed, as being benign. It is assumed you already had a formal diagnosis of the lesion you intend to have removed with the device. Benign Moles and benign skin Lesion removal can only be undertaken if the client has had confirmation from their specialist that these are benign. By signing this document you confirm you already sought medical attention in connection with the lesion (or lesions) you want to have removed and it has been diagnosed as a benign skin lesion which you can have removed for aesthetic reasons.
  • When removing benign lesions there is always a low risk of hypertophic or atrophic scarring as well as hypo or hyper pigmentation which could develop after healing. These risks can be minimised but never eliminated. You understand that no warranty can be made by the Beauty Therapist/the operator of the device or any other party that after healing none of the above will not develop.  Please be aware that certain benign skin lesions may recur despite  the method used to remove them. In any case, in the unlikely event the lesion, although previously diagnosed as benign has become red, inflamed, or sore it must be assessed by a specialist and its removal, if appropriate, can only be carried out a medical practitioner with suitable instrumentation.
  • In case of tattoo or permanent make-up removal treatments these cannot guarantee a seamless disappearance of the tattoo within one session this applies to plasma tattoo removal treatments and permanent make-up removal. Although the likelihood of scarring, hyper-pigmentation, or hypo-pigmentation are very low this always exists despite the method used to perform the treatment. It can be minimised but never completely ruled out. The tattoo removal and permanent makeup treatment involves scabbing and the formation of new skin during the healing process. Therefore the area will have a different skin texture after the scabs have fallen off. This is normal and to be expected. The area usually blend in with the surrounding area over the course of the following weeks. In any case please bear in mind that seamless results cannot be guaranteed after tattoo removal. Infections or early sun exposure during the healing period increases the likelihood of the potential adverse reactions listed above including scarring.
  • In Case of Plasma Eyelid Tightening Treatments with the “BeautyTeck” can result in some immediate reactions including redness, major swelling and pain or tenderness. Pain usually lasts up-to 24 hours after the treatment, but sometimes slightly longer. Swelling can last up to five days.  If any of these symptoms persist for more than six days, or if any other side effects develop, report them to your beauty practitioner and consult your doctor. Long term redness and slight tenderness may continue for a few weeks following the treatment.
  • It is imperative that the aftercare instructions are followed as prescribed to minimise the likelihood of Adverse Reactions.
  • There is small risk of scarring, hypo-pigmentation or hyper-pigmentation which can be minimised but can never be completely avoided, however these risks are greatly increased if the aftercare instructions are not strictly adhered to.
  • The number of sessions required to achieve the desired result will be determined by the type of treatment you request and the size of the area being treated. The minimum interval between treatments on the same area is 6 weeks. This minimum time period may be extended at discretion of your beauty practitioner, depending on your skin type and your individual reaction to the treatment.
  • The likelihood of hyper pigmentation is very low and can be minimised but never completely avoided. Hypo-pigmentation is a normal reaction in skin renewal and normally disappears after a few months. These risks are minimised by following the after-care recommendations and avoiding sun exposure and applying total sun block for the prescribed period.
  • Avoid extreme sun exposure, UV light, freezing temperatures and saunas for 2 weeks after treatment.
  • The ‘BeautyTeck’ has not been tested on children, breast-feeding or pregnant women and is therefore not recommended in these cases.
  • Treatments with the “BeautyTeck” should be avoided if you have an underlying medical condition or you are diabetic.
  • The ‘BeautyTeck’ is not recommended to be used on those clients with increased susceptibility to Keloid formation and hyper-trophic scarring.
  • IF YOU EVER HAD EPISODES OF HERPES SIMPLEX IT IS RECOMMENDED TO UNDERGO A COMPLETE ANTIVIRAL COURSE TREATMENT BEFORE UNDERGOING ANY TREATMENT WITH THE DEVICE.
  • TREATMENTS WITH THE DEVICE ARE NOT RECOMMENDED IF YOU HAVE A PACEMAKER or metal implant.
  • Effects of the ‘BeautyTeck’ for simultaneous use with peeling, botox, laser or ultrasound based treatments is unknown and should be avoided for at least two months after the last treatment.
  • There is no available data (efficacy, tolerance) about the application of the ‘BeautyTeck’ :-

a) in clients with a previous history of autoimmune diseases or receiving immunotherapy or
b) into an area which has already been treated with a filling product (especially permanent filling materials such as Silicone or Aquamid) unless it is certain that the filling product is no longer present.
c) an area treated with lasers or cosmetic lasers.

 

My beautician/aesthetic practitioner has:

  1. Provided me with sufficient information about the treatment in order to make an informed decision,and I understand the risks involved. I understand that if I do not want to take those risks I can simply abstain from any treatment with the device.
  2. Given me the opportunity to ask all questions I may have about the treatments, has answered them to the best of their ability and I have understood the answers.
  3. Provided sufficient time to consider whether I want to undergo the aesthetic treatment.
  4. Received relevant medical history information from me which I have answered to the best of my knowledge.

I have read the above and consent to receiving the treatment at my own discretion.

Client’s signature: ………………………………….. Date: ………………………

 

PHOTOGRAPHS

I authorise the taking of photographs and video footage which will be retained as a private record for the clinic and practitioner.

Client’s signature: ………………………………….. Date: ………………………

 

I ALSO CONSENT THE USE OF MY PHOTOGRAPHS AND VIDEO FOOTAGE FREE OF CHARGE FOR MARKETING PURPOSES.

Client’s signature: ………………………………….. Date: ………………………