Aesthetk Electrosurgery – Client Consent Form

AESTHETK ELECTROSURGERY- CLIENT CONSENT FORM

Client Details

First Name

Last Name

Date of Birth

Patient Gender

Phone no.

Is the Patient Under Age of 16 Years?

Yes

First Name

Last Name

Relationship with Client

Phone/Mobile

Address

Address Line 1

Address Line 2

City

Post Code

Country

Emergency Contact

Phone no.

Disability ?

Yes

GP Details

GP Practice

Where is your primary care doctor located ?

Phone Number of primary care doctor:

CLIENT MEDICAL HISTORY

Do you (does the client, if completing for an under 16) currently suffer from, or have you (they) ever suffered from any of the following?

	Yes	No
Heart condition / Angina
Blood pressure problems
Do you have a Pacemaker?
Epilepsy / Seizures
Haemophilia / Blood clotting disorders
Skin complaints e.g. psoriasis, eczema, dermatitis, lupus
Diabetes
Are you prone to fainting attacks?
Allergic response e.g. anaesthetics, jewellery
Do you regularly take any blood-thinning medicines e.g. aspirin?
Do you take any regularly prescribed medication?
Could you be pregnant?
Do you have Cochlear implants?
Have you had any Laser/IPL (recent treatment in area to be treated)?
Any other associated condition(s)?
Details of any associated problems with treatment

Please share details of the sections you said YES to:

PROCEDURE DETAILS

Operator’s name

Site on body

Type of Electrosurgery

I declare that the information I have provided on medical history is correct to the best of my knowledge and that I am not currently under the influence of drugs or alcohol. I hereby give consent for the electrosurgery detailed above to be carried out by the named operator. I confirm that I have been provided with written information on (i) the potential complications associated with the procedure and (ii) appropriate aftercare advice for the electrosurgery. I agree that it is my responsibility to read this and follow the instructions on it until the treatment area is healed. I give consent to the operator to retain the details provided on this form for a period as long as legally required.

Client Signature

Sign Here

Date / Time

Operator Signature

Sign Here

Date / Time