Personal Details

Name:

Surname:

Your Email:

Contact Number:

Address:

Next of Kin:

Relationship (Next of Kin):

Contact Number:

Address:

Medical History:

Do you suffer from any of these conditions?

HypertensionDiabetesHIVArthritisCardiac Conditions / Heart DiseasesAsthmaKidney DiseaseDepressionAlzheimer’s Disease and Dementia

Surgical History:

Have you done any operations before?

YesNo

If Yes, please mention:

Informed Consent

I,
consent to the treatment known as the Whitening Injections treatment. This treatment has been explained to me and I have had the opportunity to ask questions regarding the procedure. I understand that these treatments are not an exact science and the degree of my improvement is variable.
By my signature below, I acknowledge that I have read the information and consent and that I have been given the opportunity to ask questions and that my questions have been answered to my satisfaction. I have been adequately informed of the risks and benefits of this treatment and I wish to proceed with the Whitening/Slimming Injections treatment.

I have been informed and understand that my treatments will cost

per treatment. I also understand that any appointment that I make that is not cancelled within 48 hours I will be charged a (R150 or forfeiture of one of the treatment) no show fee.

The Royal Wellness will not be held responsible for any adverse reaction that might have been caused by the contents of the treatments offered. Strictly no refunds on any treatment or products offered.

Patient Name (print):

Patient Signature: (use mouse to sign in box below)

Signed Date:

Witness: