Skin Tag Removal Consent Form - Kenosis Beauty Institute

PAIN: The treatment is mostly, but not always painless and every effort is made to ensure a painless treatment. We use at optical numbing cream that we leave on the skin for 60 minutes. This can be explained to you in detail should you so require. However, there is some discomfort associated with the treatment and the subsequent healing. Home care will be discussed with you in detail. For 3-5 days you are not allowed to wear foundation on the scabs. *

Agree

SWELLING: There may be swelling day 1-2, especially the eye area, after waking on the day following the procedure. This will subside when your lymphatic system starts draining as it is stimulated by movement. *

Agree

HYPERPIGMENTATION: I understand that there is a possibility of hyperpigmentation resulting from the treatment, especially in individuals prone to hyperpigmentation and the non-use of SPF as recommended. If you have small brown spots, this is temporary post inflammatory pigmentation that will completely subside in 3 months on its own. *

Agree

APPEARANCE: After the treatment the skin is discoloured and spotty and may appear red for 1-2 months post treatment. I am aware that as my skin heals, at its own pace, the spots/scabs will disappear after 5-7 days and the skin will appear rejuvenated and firm. *

Agree

POST PROCEDURE CARE: I will follow the aftercare instructions. *

Agree

OTHER INFORMATION: I understand that should I have an infection, adverse reaction or allergic reaction to this procedure, or the post care products recommended, I must notify my doctor immediately. *

Agree

NO GUARANTEES: I understand that no warranty or guarantees have been made to me as the outcome and results of this procedure as it is not an exact science and compliance be myself will affect the final result. *

Agree

TREATMENT EXPECTATIONS: I understand that the information above is not meant to alarm or scare me. It is simply to enable me to make an informed decision as to whether I wish to proceed with the procedure or refrain from continuing. Every client is an individual, with individual circumstances and influences, therefore the outcome will vary in expectations, requirements and actual results. Strict adherence to the home care is recommended as this is critical to promoting further excellent results. *

Agree

Contraindications *

I am not a haemophiliac (Excessive bleeder)
I do not have epilepsy
I do not suffer from keloid scaring (excessive scaring)
I do not have a pace maker (heart device)
I do not have HIV or AIDS or any other communicable disease

Other:

Payment: I agree to pay the fees for the treatments and understand that they are not refundable and are payable at the commencement of each treatment. All our prices are subject to change without prior notice. Any interest, legal demands, debt collection or tracing fees will be paid by the client for unpaid accounts. Payments are due on the day of the treatment.

Agree

Consent: I believe that I have sufficient information to give informed consent.

Agree

I agree to adhere to all safety precautions and regulations during the treatment and to follow all aftercare instructions.

Agree

I understand that if I have any infection, allergy reaction or adverse to the procedure, I must notify my doctor.

Agree

Name *

First

Last

Date of Birth *

Phone Number *

Email *

Physical Address *

Name of employer and Occupation *

Date of Procedure *

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