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CONSENT FORM

Dr Alisha Aesthetics

Patient Details

First name*

Last name*

Phone*

Email*

Medical Information

Do you have any allergies?*

Do you have any health conditions?*

Are you currently taking any medication?*

Treatment(s) to be performed*

Dermal Fillers

Anti-Wrinkle Injections

Microneedling

Skin Boosters

Other

Have you had any filler in the past?*

Yes

No

Consent & Acknowledgements

Photo Release*

I consent to the use of my before and after photos for educational or promotional purposes

I do not consent

Do you consent to the procedure?*

Yes

No

Procedure Understanding: I acknowledge that the procedure(s) I am undergoing have been explained to me in detail by Dr Alisha. I understand the purpose, the potential risks, and the expected results.

Date*

Day

Month

Year

Customer signature (please type your name in all caps)*

Based In Hull & Bury

Dralishaaesthetics@gmail.com

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CONSENT FORM

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