Trichology Consultation and Consent

Client Details


Medical History


Emergency Contact Details


Consultation


Hair/Scalp Care


Diet


Photos

If possible, please upload clear photos of your hair loss to help us be better prepared for your appointment.


Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me. 

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Trichology treatment(s) to be carried out.



Tap or click on the signature above to sign


SUBMIT

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