WP E-Signature by Approve Me - Sign Documents Using WordPress -

Microneedling Consent

Important Background to the Consent Process

Your clinician wishes to help you make an informed decision about your treatment options and any relevant alternative options. You may at any time decline treatment even after giving your consent.

Whilst your clinician will make every effort to understand what significance you would attach to any particular risk it is important to us that you feel comfortable enough to question the clinician on any point of concern during this process. Please feel you have as much time as you wish to reflect on the information given before agreeing to proceed with the treatment.

Purpose of Treatment

You have presented with concerns which have formed the basis of a clinical discussion and examination. The purpose of the proposed treatment is to address your concerns either individually or in combination with other modalities of treatment.

Outcomes

Your clinician will endeavor in good faith to employ the principles of best practice in delivering your treatment. Each patient is individual and response to treatment will vary from patient to patient and treatment to treatment. As such it is difficult to guarantee outcomes will always meet your expectations.

Important Considerations

Every care is taken to deliver the products in a manner which will minimize risk, however you should be aware of the risks, as one may exist upon which you place particular significance.

Patients are advised to take in to account all these potential risks before consenting to treatment. Please make your clinician fully aware of your expectations prior to giving consent.

Model consent to treatment

I consent to acting as a model for the purpose of training (under supervision). 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 the 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.

Training course times may be delayed due to unforeseen circumstances. It may take longer training the students or the student may need more support. So please allow extra time in case this event occurs. Your full payment for your treatment as a model is non-refundable. If the circumstances occur outlined above and/or cancellation your payment is non-refundable. The full payment will be made prior to attending the training academy.Every procedure involves a certain amount of risk and it is important that you understand the risks involved. An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your practitioner to ensure you understand the risks. Potential complications and consequences of – Microneedling - The primary risk is skin irritation after the procedure. Other side effects could include: swelling,Discomfort at the site,Rredness,Bruising, Dryness,Flaking of the skin.Bleeding is an uncommon reaction to microneedling, though it may be more likely to occur after a deeper treatment.

I consent to Ampika’s Aesthetics using photographs being stored on a training file and be used for social media purposes photographs and/or video recordings including images of me both internally and externally to promote the Training Academy. These images could be used in print and digital media formats including print publications, websites, e-marketing, posters banners, advertising, film, social media, teaching and research purposes. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that some overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides. I understand that some images or recordings may be kept permanently once they are published. I have read and understand the conditions and consent to my images being used as described.

I am signing to consent to my treatment being administered at Ampika’s Aesthetics. On behalf of the training academy Ampika’s Aesthetics - Ampika’s Hair Make Up and Beauty. You are agreeing to be a model and hold no responsibility towards Ampika’s Aesthetics for any procedures that may incur any personal dissatisfaction or cause of concern.

Any models wishing to seek any legal or liable action will not be permitted to do so once signing this disclaimer you are excepting full responsibility to allow a student to carry out your Microneedling treatment.

We are a training academy providing our students with a module in which they facilitate live models in order for each student to get accreditation in the relevant service.

Medical professionals who observe the students have the right to refuse models who aren’t suitable for a treatment. This would be at their discretion.

We do not support any negative comments on social media or any other rating platforms as you will be refused entry to obtain any further treatments with Ampika’s aesthetics training academy at any one of our locations .

These Students who are responsible for carrying out the treatment under medical supervision, are not fully qualified to carry out Microneedling unassisted. Therefore, you understand the risk that this may pose. Any concerns must be addressed whilst you are present in the training academy. Whilst all the trainers accommodate you to ensure you are fully satisfied with your treatment, we are unable to rectify problems weeks after you have undergone the treatment. If there are any concerns then please contact the training academy within 48 hours of treatment via email at [email protected].

I understand I am aware the results today may not be applied to their full effect as I am only a model and for the treatment to reach its full effect I may need to book back in for further treatments.

By signing this form you have agreed to consent to adhere to our vaccination policy.

Any Current Medication taken?

Yes

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signed by Ampika Pickston
Signed On: March 12, 2024

Timestamp

Audit

November 29, 2020 10:21 am BST

Microneedling Consent Uploaded by Ampika Pickston - [email protected] IP 2a02:c7c:e64f:6400:7163:3f0b:e0f1:eda

February 1, 2021 9:49 am BST

Ampika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:c553:e3b7:94b6:6079

March 24, 2021 2:25 pm BST

Ampika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8

May 17, 2021 2:33 pm BST

Ampika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:8c91:4647:3701:7107

June 9, 2021 11:14 am BST

Ampika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:ecb0:e2cc:50f1:3510

March 12, 2024 9:20 am BST

Ampika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a02:c7c:e64f:6400:7163:3f0b:e0f1:eda

March 12, 2024 9:20 am BST

Ampika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a02:c7c:e64f:6400:7163:3f0b:e0f1:eda