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Consent Form

What are your skin concerns?
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Skin Breakouts?
Does your skin feel?
Please TICK if the following apply:
Do You Suffer From Any Of The Following:
Have You Recieved Any of The Following?
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.
Do You Regulary Eat Any of The Following:
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.
*
Have You Ever Suffered From:
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Have you:
Do You Suffer From Any of The Following:
Have You Taken Any of the Following in The Last 6 Months:
Allergies
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*
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*

I have received and understand the full explanation of the treatment procedure, including risks and side effects. I understand that results may vary and that multiple treatments are required for optimal results. I agree to follow the pre- and post-treatment care instructions to minimise risk and optimise results. I understand that I must notify the clinic of any changes in my medical condition, medications or recent sun exposure. I consent to a patch test before treatment to assess my suitability. I understand and agree to the cancellation policy (fees may apply for late cancellations or missed appointments). I certify that I have provided accurate medical information to the clinic.

Thanks for submitting!

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