PDO THREAD LIFT 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):
Auto-immune connective tissue diseases, HIV, Pregnant or breastfeeding. *
CONSENT

I confirm that it is my responsibility to ask sufficient information about the treatment and product.
The PDO threads last for up to 2-3 years however this can vary from individual to individual and no guarantee can be made as to the results of my treatment.
I give permission for the administration of topical anaesthetic to ease any discomfort. *
SIDE EFFECTS & PRECAUTIONS

Bleeding, swelling and bruising can last 2- 7days, use an ice pack to reduce the swelling and arnica to help reduce any bruising. Do not rub treated area and only gentle cleansing 24 hours post treatment. Slight tightening sensation as new collagen is produced. Infection, follow correct aftercare. Excessive smoking and alcohol intake may affect any healing and may limit the success of long-term effects. *
ACKNOWLEDGMENT

I certify that I have thoroughly read and understand the contents of this form. I understand that I am responsible for all costs payable at the time of service and I pay for treatment not the outcome.
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*