Patient consent

Name and Surname*

City

Street

No

Bldg

Floor

Apt

Date of Birth

Email

Phone*

Indicate an emergency contact person (eg: a girlfriend / name, phone no. )

allergiesherpesdiabetesacnecardiovascular diseases

pregnantbreastfeedingyou are on the menstruation period

antibioticsanticoagulantscortisonei am not under any medical treatment

I hereby give consent to the administration for the use of any type of anesthetic considered necessary and I am aware that all forms of anesthesia involves risks. I authorize the physician chosen, to do what considers necessary, given the medical knowledge and professional judgment.

I confirm that I had time to think before deciding. I freely and voluntarily consent to the injection procedure. I am aware that injection procedure may also have a number of post-intervention risks and effects, some of which are inevitable (allergic / toxic reactions to drugs and anesthetics, hematoma, bruising, edema / bruising or inflammation).

I declare that I am aware of these risks and accept them without further material or moral damages to the physician or clinic. I am aware that a form will be given to me, with instructions that I will have to follow after the procedure. I understand and accept that no guarantee can be given regarding the aesthetic outcome of the procedure. I admit and was explained to me by the physician that there may be more factors that affect the outcome of the requested intervention and that is why, if i am dissatisfied with the result, i have to proceed as follows:

1. Contact Swiss EstetiX at +40 799 822 884 and schedule a consultation with the doctor who injected me.

2. Contact Swiss EstetiX management by email at [email protected], presenting the case.

3. I have a duty to not to bring any damage to the image of the Swiss EstetiX doctors or clinic through public posting on Facebook or other communication channels, otherwise I will be obliged to bear the legal consequences for image damage caused by public denigrator and slanderous

I agree to be photographed or filmed before, during or after the intervention in order to track the result, and if the materials will also be used for medical presentation / research, I would like my identity not to be specified.

YESNO

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