Consent Form

Further details and post treatment Instructions can be found on this link www.estelaza.com/medical-micro-needling

Further details and post treatment Instructions can be found on this link www.estelaza.com/mesotherapy

Further details and post treatment Instructions can be found on this link www.estelaza.com/oscar

Further details and post treatment Instructions can be found on this link www.estelaza.com/platelets-rich-plasma

Further details and post treatment Instructions can be found on this link www.estelaza.com/q-switch-bleaching

Further details and post treatment Instructions can be found on this link www.estelaza.com/laser-hair-removal-bleaching

Further details and post treatment Instructions can be found on this link www.estelaza.com/laser-pigmented-lesions-removal

Further details and post treatment Instructions can be found on this link www.estelaza.com/laser-tattoo-removal

Further details and post treatment Instructions can be found on this link www.estelaza.com/007-treatment

Further details and post treatment Instructions can be found on this link www.estelaza.com/hollywood-carbon-peel

Further details and post treatment Instructions can be found on this link www.estelaza.com/fat-lipolysis

Further details and post treatment Instructions can be found on this link www.estelaza.com/botox

Further details and post treatment Instructions can be found on this link www.estelaza.com/dermal-filler

Further details and post treatment Instructions can be found on this link www.estelaza.com/bbl

Further details and post treatment Instructions can be found on this link www.estelaza.com/facial

Further details and post treatment Instructions can be found on this link www.estelaza.com/estelaza-secret

Further details and post treatment Instructions can be found on this link www.estelaza.com/threads

Further details and post treatment Instructions can be found on this link www.estelaza.com/chemical-peel

Further details and post treatment Instructions can be found on this link www.estelaza.com/infini-radio-frequency-micro-needling

 

As a patient, you have the right to be informed about the proposed treatment so that you may make an informed decision whether or not to undergo the procedure after knowing the risks and complications involved. This disclosure is not meant to alarm you but is simply an effort to better inform you so that you may give or withhold your consent.

Upon signing below:

  1. You confirm that the nature and purpose of this treatment have been explained to you, and any questions you have regarding this procedure have been explained to your satisfaction.
  2. You confirm that you fully understand that the effects of this treatment are individual and vary depending on areas treated, skin type, medical history, your compliance with pre- and post-treatment instructions and you are fully aware that no guarantee can be given as to the final result.
  3. You understand that while every precaution will be taken to prevent complications and that while complications from this procedure are rare, they can and sometimes do occur. You accept responsibility for any complications that may occur and thereby absolve Esteleza Clinic of any blame resulting therefrom.
  4. You understand that this procedure is “elective” and not covered by insurance and that payment is your responsibility. Any expenses which may be incurred for the medical care you elect to receive outside of this office, such as, but not limited to the dissatisfaction of your treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is non-refundable.
  5. You understand that This consent form is valid for all future similar treatments performed on you, and you will alert the staff if there are any future changes to your medical history and/or you become pregnant.
  6. You consent to the taking of photographs and authorize their anonymous use for medical audit and public education, medical study or research and documentation for your medical records.
  7. You certify that you have read and fully understood the above paragraphs and that you have had sufficient opportunity to discuss and have your questions answered and you certify that you are a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon your spouse, relatives, legal representatives, heirs, administrators, successors and assigns
  8. You agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.
  9. You confirm that you were informed to check the website for further details on what to expect from this treatment and the post-treatment instructions on the link below.

⬜ If you tick this box and sign at the end of this paragraph you authorize Estelaza Clinic, to publish photographs taken of you, for use with the Estelaza Clinic print, digital and video-based marketing materials. and you acknowledge that your participation is voluntary and you agree that publication of those photos confers no rights of ownership or royalties whatsoever.

You therefor release Estelaza Clinic, its contractor, its employee and any third parties involved in the creation or publication of marketing materials, from liability for any claims by you or any third party in connection with your participation.

We want you to have an outstanding result, If you have any questions or unexpected concerns, please call the clinic for assistance. A physician can always be reached after hours for urgent issues.

 

Patient Name & Signature

Doctor Name & Signature

Witness Name & Signature

Estelaza Clinic is the brainchild of Dr. Nouf Al Raeesi who has gained her experience as an expert skin specialist working with some of the top Skin specialists in the medical field for over 7 years.

Nouf’s passion and dedication to providing life-changing skin revision treatment programs using some of the best skincare and medical technology on the market has gained an ever growing reputation amongst current and new patients.

Nouf has a certified degree of Bachelor of Medicine from Dubai Medical College for girls, with highest measure of educational brilliance she has obtained an Arab Board of Family Medicine, with all the Arsenals and valuable clinical experiences.

She has been a member of Royal College of General Practitioners, she has been undertaking fellowship program at American Academy of anti-aging Medicine (A4M) in advancement of technology to detect, prevent, and treat aging related disease.

She has undergone and finished derma-medical foundation and advanced courses, in addition teaching and training aesthetic medicine are a part of her passion.