Forms | DA Academy

Model consent form

First Name

Last Name

Phone

Appointment date

Any medical conditions or medication taken?

Are you currently undergoing any dental treatment? If ‘Yes’, please give details and dates:

Are you Pregnant/Breast feeding/Lactating or trying to get pregnant?

Have you had any sunbed treatment, dermabrasion, skin peels or laser skin resurfacing in the last 6 weeks?

Do you have any skin or neoromuscular disorders? Do you use any Anticoagulants? E.g. Warfarin/Aspirin?

Are you particularly prone to fainting, bruising, keloid scarring or bleeding? Do you have any other medical/health conditions we should be aware of?

Do you have any allergies?

Do you have any permanent implants in your face? Any facial surgery or significant injury on your face?

When was the last time you had any Ant Wrinkle/Dermal Filler / Advanced Skin Booster/ PDO Threads or any aesthetics procedure done?

Do you suffer from cold sores?

Have you suffered from Asthma/bronchitis / High/low blood pressure / Stomach ulcer/colitis / HIV/hepatitis / Venereal disease/STD / Myasthenia gravis / Lambert-Eaton syndrome / Thyroid problems / Convulsions / Depresion / Diabetes / Bell’s/facial palsy / Skin disease (e.g. acne) or ny other? If yes plese give details

I consent to acting as a model for the purpose of training practitioners (under supervision) in the administration of injectables . The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had an opportunity to have all my questions answered to my satisfaction. I have answered the questions regarding my medical history to the best of my knowledge . I consent to my photographs being stored on a training file and social media. Agree to the following: • Procedure might take longer then expected •there may be swelling, bruising, discomfort during and after a procedure. •Although this is rear, the results may be uneven or asymmetrical. •I am paying for the cost of the products used during my treatment. The money paid today does not cover any further corrections or follow up appointments that may be needed. •Due to only paying for the cost of the product I am not eligible for any form of refund. Should I require any work to be dissolved for medical reasons I understand that no refunds will be given. •Should I require a top up after today’s appointment I understand that there will be further costs to this. •Being a model during this course makes me exempt from leaving any negative feedback regarding the end result of the appointment.

I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my participation in aesthetic procedures. I understand that I need to keep the practitioner/s updated of any changes in my health or medications. PUBLICITY MATERIALS I authorise the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.

I consent to the treatment described

I have not knowingly withheld any medical information

The information given is correct to the best of my knowledge

I fully understand all potential risks and complications

All risks of the procedure fully explained to me

Thank you! We’ll be in touch.