Consent

Ear wax removal / check up

Consent forms for Ear wax removal / Ear check ups

Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

Day

Month

Year

Medical History

Hearing aid user

History of ear infections

History of ear surgery

Tinnitus

Vertigo/balance problems

Recurrent wax build up

Symptoms of blockage/ pain

Hearing loss

Other

Which ear(s) are affected

Right

Left

Both

If you answered yes to any of the medical questions above, please supply additional information.

Have you used ear drops?

Yes

Initials*

Signature

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I declare that the info I’ve provided is accurate and complete.

First name

Last name

Phone

Birthday

Day

Month

Year

Address

Select what's relevant to you:

Pregnant

Breast feeding

Eczema

Psoriasis

Dermatitis

Active cold sore

Open cuts/ wound

Active acne, pustules or cystic breakouts

Rosacea

Used Retin A

Diabetic

Epilepsy

Have you taken roaccutane in the last 12 months?

Do you have any allergies? ( especially to aspirin,/salicylates, TCA or skincare ingredients)

Do you have any other significant medical conditions (heart, liver, kidney or immune?)

Do you have a history of sensitivity to skincare treatment/peels?

Have you had any other skin treatments in the past 2–4 weeks (laser, microdermabrasion, dermaplaning, chemical peel, microneedling, injectables)? If yes, please state what:

Are you currently using retinoids (tretinoin, Retin-A, adapalene, retinol) or prescription-strength acne products?

Do you regularly use AHA/BHA products, benzoyl peroxide, or exfoliating scrubs? If yes, please state what:

Do you tan (sunbed or natural sun exposure) regularly? If yes, please state:

The nature and purpose of a Peel.

Possible side effects include: temporary redness, tingling, flaking, peeling, breakouts, tightness, hyperpigmentation (especially if aftercare not followed).
Results vary per individual; no guarantees can be made.
The importance of following pre- and post-care instructions (SPF, no picking, avoid actives for 5–7 days).
Multiple treatments may be required for best results.

I have disclosed all relevant medical history, medications, and allergies.

I understand the potential risks and side effects of this treatment.

I understand that results vary and no guarantee can be made.

I will follow the aftercare advice provided.

I release Clinic El from liability in the event of an adverse reaction.

DeclarationI confirm that I have provided full and accurate information regarding my medical history, medications, allergies, and skincare use. I have read and understood the information contained in this consent form, including the nature of the treatment, possible risks, and the aftercare advice. I understand that results may vary and that no guarantee of outcome can be made.

I consent to before-and-after photographs being taken as part of my treatment record. These images will be stored securely with my client file in line with GDPR requirements and will not be shared without my written permission.

By signing below, I confirm that I understand the above and give my consent to proceed with treatment.

Date picker

Signature

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BioRePeel

Before your treatment, we’ll ask you to complete a consent form to ensure it’s safe and suitable for your skin. This covers your medical history, current skincare routine, and any allergies or sensitivities. It’s also your opportunity to ask questions and make sure you understand the treatment, possible side effects, and aftercare. By signing, you confirm that you’ve shared all relevant information and are happy to proceed.

Microneedling - SkinPen

Before your treatment, we’ll ask you to complete a consent form to ensure it’s safe and suitable for your skin. This covers your medical history, current skincare routine, and any allergies or sensitivities. It’s also your opportunity to ask questions and make sure you understand the treatment, possible side effects, and aftercare. By signing, you confirm that you’ve shared all relevant information and are happy to proceed.

Full name

Phone

Are you currently pregnant or breastfeeding?

Yes

Are you currently taking, or have taken in the last 6 months - oral isotretinoin / Roaccutane / Accutane?

Yes

If yes - What? When did you last take it?

Do you have any active skin cancer or a history of skin cancer in the area to be treated?

Yes

Do you have any open wounds, cuts, sore, irritation or broken skin in the treatment area?

Yes

If yes, What/ where?

Do you currently have any active acne or inflamed breakouts in the treatment area?

Yes

Do you currently have, or have had a cold sore/ herpes simplex outbreak, wart or bacterial/ fungal skin infection?

Yes

Do you suffer from eczema, psoriasis, rosacea, dermatitis or another chronic skin condition?

Yes

If yes, which one? Tell me about it.

Do you have a history of keloid, abnormal/ raised scarring?

Yes

Do you take blood thinning medication?

Yes

Do you have diabetes, or an condition affecting wound healing?

Yes

Do you have a known allergy or sensitivity to stainless steal, topical anaesthetic, antiseptics or purified water?

Yes

Lift HG contains purified water, glycerin, carbomer, potassium hydroxide, disodium EDTA, phenoxyethanol, capryly glycol and sorbic acid.

Are you taking any medication, undergoing medical treatment, or do you have any other health or skin condition that may be relevant to your treatment?

Yes

If yes, please provide details

Multi choice

Had excessive sun exposure or sunburn within the last 24 hours?

Used topical retinoids/ exfoliators within the previous 24 hours?

Applied fake tan or tanning drops to the treated area in the last 24 hours?

Multi choice

I understand the treatment and expected results - The skinpen microneedling treatment has been explained to me. I understand that results may vary between individuals, cannot be guaranteed and that a course of treatments or more may be recommend.

I understand the possible recations and risks. I understand that temporay redness, dryness, tightness, peeling, tenderness, swelling, sensitivity or discomfort may occur and that less common complications may include infection, cold sore reactivation or changes in pigmentation.

I confirm my medical information is accurate. I have disclosed all relevant medical conditions, medications, allergies and skin concerns and agree to inform my practitioner of any changes before future treatments.

I give my consent. I have had the opportunity to ask question, understand the treatment, possible risks, expected results and have received and understood the aftercare advice given to me - not to apply ANYTHING or get anything on my skin expect Lift HG for the first 24 hours. I agree to follow the recommended after care instructions.

Signature

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