Patient Consent Form

Thank you for your payment. Kindly ensure that you complete the consent form in full so that we can provide you with the best possible care and consultation

Neoshape Patient Information
Name
Name
First Name
Last Name
Medical doctor
Medical doctor
First Name
Last Name

Elected Doctor:

Doctor Alistair McAlpine
MBBCh (Wits)
BDS (Wits)
PR No: 0140000542695

Informed Consent

The answers to these questions are important to your health care and the appropriateness of the choices available to you. It will affect the information, instructions and warnings provided to you, and may affect the treatment choices available to you and in some cases it may be in your interest not to proceed with a treatment. Clients are advised to consult their medical practitioner should they be in any doubt as to the appropriateness of commencing treatment.

Have you previously received any aesthetic treatments?
Have you ever experienced any negative reactions or responses to the local anaesthetic?
Within the last six months have you been under a physician's care?
Are you currently on any medication including dietary supplements, vitamins, aspirin, steroids, anticoagulant, diuretics or slimming tablets?
Do you use Roaccutane, Retin A Renova or any other prescription skin product?
Have you ever been admitted to hospital?
Have you had previous surgeries including cosmetic procedures?
Have you ever experienced severe allergy / anaphylaxis to a product/treatment/medication etc.?
Do you have any known allergies?

Have you suffered from any of the following:

Heart disease/ Angina (severe chest pain)/ Vascular aneurysms?
Hormonal/ Thyroid problems/ Polycystic Ovarian Syndrome?
Auto-immune disease (e.g. arthritis, lupus)?
Asthma/ Bronchitis?
Convulsions?
Cancer?
Depression/ Psychoses/ Nervous condition/ Uncontrolled Hypertension?
Venereal disease?
Bells/ facial palsy?
Glaucoma/Cataract?
High/ low blood pressure?
Haemophilia or clotting abnormalities?

Do you suffer from any of the following:

Facial cold sores?
Diabetes/ Kidney disease?
Stomach ulcer/ colitis (inflammation of the colon)?
Skin disease (e.g. shingles, herpes, acne)?
HIV/ hepatitis?
Arthritis?
Glaucoma/ cataract?
Phlebitis (inflammation of blood vessel walls)?
Hypoglycaemia (low blood sugar)?
Myasthenia gravis or Eaton Lambert Syndrome?
Epilepsy/ Seizures?
Porphyria?
Keloid scarring or a tendency to develop scar tissue?
Acute rheumatic fever or recurrent sore throat?
Do you have a pacemaker or internal defibulator?
Do you have any metal pins or plates?
Are you currently trying to fall pregnant, pregnant or breastfeeding?
Do you partake in regular exercise?
Do you smoke?
Do you drink alcohol?

Consent

1. I herewith agree to the following:
1.1 That the staff of the centre perform the treatment(s) and that they are not held liable for any guarantee, warranty or assurance of the results that may be obtained unless gross negligence arises;
1.2 I certify that I am a competent adult of at least the age of eighteen and this is my free and voluntary decision that is executed;
1.3 I have answered all the questions contained herein with accuracy, honesty and to the best of my ability. If there are changes to my medical history, operations or medications I will be responsible for informing the centre of the updates and any other serious conditions that may be relevant;
1.4 I agree to adhere to all safety precautions and regulations during the treatments and to follow all aftercare instructions.
1.5 The centre does not take responsibility for therapy's done at other practitioners or centres that may cause side effects to the treatment(s); and
1.6 My digital submission of this form indicates my informed consent to the treatment(s) and my acceptance of the conditions outlined herein.
2. I hereby authorise NeoShape to compile, collect and retain at the premises of NeoShape (or any branch thereof) all of my personal health information relating in any way to any treatment or procedure of any kind which I undergo and I hereby instruct NeoShape not to release such information or any copy thereof to any person without my specific consent. I specifically authorise NeoShape to make such personal health information available only to my elected Doctor referred to above and then only at the premises of NeoShape and I hereby specifically terminate any doctor patient relationship with any other Doctor (other than my elected Doctor referred to above) who I may have previously consulted at the premises of NeoShape.
3.11 I absolve NeoShape of any liability for damage to such property through any means whatsoever. I specifically authorise Neoshape to copy my personal health information for Neoshape's record purposes as it, at its sole discretion, deems necessary.
3.2 I hereby instruct NeoShape not to release my personal health information or any copy thereof to any person without my specific consent. I specifically authorise NeoShape to make such personal health information available only to my elected Doctor referred to above and then only at the premises of NeoShape and I hereby specifically terminate any doctor patient relationship with any other Doctor (other than my elected Doctor referred to above) who I may have previously consulted at the premises of NeoShape.
4. I have read and understood the treatment information guide relating to my treatments at NeoShape.
4.2 I have been advised that all treatments may differ due to variables such as age, lifestyle etc.
5. NeoShape may contact me regarding new services and/or goods that may be on offer, including promotional offers?
6. I acknowledge that NeoShape has a strict no refund policy.
7. If I am to develop a medical condition during my course of treatment, which excludes me from my treatment, NeoShape will not be held liable for refund.

Consent
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