Aesthetics Model Consent Form

Model's Details

Model Name: *

Model Email: *

Model Contact Number: *

Model Address *

Model City & State *

Model Zip Code *

Model Date of Birth: *

I CONFIRM I AM 21+ YEARS OF AGE *

YES

Treatment Type: *

BOTOX DERMAL FILLER FAT DISSOLVE PDO THREADS SCULPTRA MESOTOX

Check all that apply

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Medical History

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Are you currently taking any medications? *

Please provide more detail: *

Do you have any allergies? *

Please provide more detail: *

Do you have any medical conditions? *

Please provide more detail: *

Are you currently, or possibly may be, pregnant? *

Additional Notes:

Treatment 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) named above and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given as indicated above 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 treatments named above I will inform the trainer during, or immediately following the treatment.

I consent to being a model for the purpose of training cosmetic injectors / aestheticians / nurses / PA's / NP's / doctors, under the supervision of certified/accredited trainer in the administration of the treatment named above.

The use and indications for the products that I will be treated with have been explained to me by the trainer and I have had the opportunity to have all my questions answered to my satisfaction.

I have signed a separate product specific consent form.

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

Media Consent

From time to time we may want to take photos or/and videos before, during and after your treatment. We may want to use these photos / videos for educational and promotional purposes including, but not limited to, staff training materials, newsletters, flyers, website, printed advertisements, digital advertisements, social networking sites and other print or digital communications.

I consent to the use of photos and videos as indicated by me on this form.

I understand I can revoke this at any time by contacting the clinic directly.

I can confirm that I have read, or been made aware of how these photos or / and videos will be stored within the organisation.

Please use this form to confirm for which purposes we have the right to use photos or/and videos of you.

Do you give us permission to take photos / videos of you pre, during and after treatment? *

Model's Signature: *

Tap or click on the signature above to sign