FIBROBLAST FORM

Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Phone*
Email Address*
Address*
Postcode*
Candidates who are contraindicated (who we are unable to treat): HIV, Pregnant or breastfeeding. *
GP consent: Epilepsy, insulin dependent diabetes, haemophilia *
CONSENT

I confirm that it is my responsibility to ask sufficient information about the treatment.
I understand the importance of my accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I understand that there are no guarantees as to the success of my treatment. *
SIDE EFFECTS & PRECAUTIONS

Swelling and inflammation (usually 3 to 7 days), apply Silver Colloidal Gel or Aloe Vera up to three times per day until scabs have formed and then all flaked off, itching, stinging sensation.
Avoid: product, exercise 1 week. Steam and sauna sunbeds during your 10 – 12 week healing period. Cleanse daily with lukewarm and cotton pad, pat dry with clean tissue. MUST apply SPF 50+ while your skin is in the healing stages (pink in colour) 12 weeks (and ideally longer).
It can actually take 8 to 12 weeks for the full effects of your original treatment to be seen. *
ACKNOWLEDGMENT

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.
I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.
By accepting, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
I hereby give consent to perform this and all subsequent treatments with the above understood.
I hereby release the practitioner from liability associated with this procedure.
I hereby authorise Dolly Patel to administer such treatment to me and agree to hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability. *
Sign Your Name*
Date*