Consent Questionnaire For Client Treatment

Which Treatment is this consent for? (please type in Other if not listed)

Microneedling Halo IV Drip Mesotherapy Other

Can you confirm you that you have read this treatment information?

Yes No

Issued on:

Do you understand the information you have been provided?

Yes No

Do you feel sufficient information has been provided to you, to enable you to consent?

Yes No

Has your consent been freely given?

Yes No

Do you have any medical conditions?

Yes No

Are you pregnant or breastfeeding?

Yes No

Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy, myasthenia gravis, or Lambert-Eaton syndrome)?

Yes No

Do you have an autoimmune disease?

Yes No

Do you have any skin conditions?

Yes No

Do you have any known allergies or have ever had anaphylaxis?

Yes No

Do you have any active infection at the intended site of procedure?

Yes No

Are you taking antibiotics or other prescription medications?

Yes No

Is there any other Medical and/or Social History that we should know? If so, please provide full detail here.

Yes No

What are your aims/motivations for having the procedure and the desired outcome? Please provide full details here.

Have you had this or a similar treatment before? If so, did you experience any problems? Please provide full details here.

Yes No

Do you have any concerns? If so, please provide full details here.

Yes No

Is there anything else we should know? Please provide full details here.

Yes No

I will retain this information throughout the course of my treatment and refer to it as required.

Yes No

CLIENT’S NAME (Please print)

All our treatment are for 18+ only. Can confirm that you are at least 18-years-old or above?

Yes No

CLIENT’S Signature

You can draw on the left or type on the right.

DATE

Practitioner Signature

Date

Once completed, download the pdf. Your practitioner will review the pdf and sign.

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K1 Derma Lab

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K1 Derma Lab

K1 Derma Lab is your premier destination for advanced aesthetic treatments in East London. Specialising in anti-wrinkles treatment, microneedling, HIFU, PRP-scalp and face, and bespoke Skin Rejuvenation, we help you enhance your natural beauty with subtle, stunning results.

Disclaimer: We're 18+ only. All treatments require a consultation first. Please consult your healthcare provider before proceeding, and note that we don't diagnose or treat medical conditions - we're here for aesthetics only. → continue reading..

Proudly serving East London E1, E6 1BB and neighbouring borough of Newham, Redbridge, Wanstead, Essex, Havering; offering expert service in Microneedling,Vampire/Plasma Facial,PRP Hair Loss Treatment, Under Eyes Rejuvenation,B12, Glutathione Biotin Injection, Chemical Peels Skin Boosters DNA Polynucleotides

K1 Derma Lab is a trading name for K1 Beauty Aesthetics Ltd Company Registered in England. Number 14812611 . Head Office 368 Green Street (Rear Unit), Newham. London. E13 9AP

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