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Absent owner treatment consent... Absent Owner Treatment Consent Form To be filled out by the owner and used in case their pet(s) needs emergency care at: Owner Name: Phone Number: Address: Departure Date Return Date Contact Phone

Hair removal consent form LASER HAIR REMOVAL CONSENT FORM Patient name Treatment sites I hereby authorize White Pearl Medical Spa under Dr. Altieri s supervision to perform laser or light based hair reduction on me. I understand that this procedure works on the growing hairs anagen and not on dormant hairs. I understand that I will require several treatments to obtain a significant long-term reduction of hair growth. I understand I may experience fewer thinner lighter slower re-growth of hairs temporary hair loss or permanent hair reduction* I understand that it is only effective on hair with color and may not treat white grey blond or red hair. I understand that genetics hormones medication and hair color may interfere with hair loss and that I may not respond at all* I understand photographic documentation will be taken and used as needed by White Pearl Medical Spa* The procedure may result in the following adverse experiences or risks DISCOMFORT Some discomfort may be experienced during treatment. REDNESS/SWELLING/BRUISING Short term redness erythema or swelling edema of the treated area is common and may occur. There also may be some bruising* SKIN COLOR CHANGES During the healing process there is a possibility that the treated area may become either lighter hypopigmentation or darker hyperpigmentation in color compared to the surrounding skin* This is usually temporary but on a rare occasion it may be permanent. WOUNDS Treatment can result in burning blistering or bleeding of the treated areas. If any of these occur please call our office. INFECTION Infection is a possibility whenever the skin surface is disrupted although proper wound care should prevent this. If signs of infection develop such as pain heat or surrounding redness please call our office 210. 495. 4397. SCARRING Scarring is a rare occurrence but it is a possibility if the skin surface is disrupted* To minimize the chances of scarring it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff* PARADOXICAL HAIR GROWTH Stimulation of terminal hair growth following photo-epilation* Can occur within or adjacent to treated area* I acknowledge the following pre-treatment rules have been discussed with me and I am aware of the possible complications/risks involved with the procedure and subsequent healing period SUN/UV EXPOSURE Prolonged or excessive sun exposure or tanning within the last four weeks including tanning beds spray tanning and bronzers are not allowed prior to treatment. No UV exposure for 3-5 days post treatment. SHAVING - The area s to be treated must be freshly shaven prior to appointment. Shaving is required throughout the treatment plan no waxing tweezing threading hair removal creams or bleaches are to be used at all* MEDICATION - No UV sensitive medications including most antibiotics for 10-14 days prior to treatment. For women of childbearing age By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment.

Downloadable esthetician conse... Client Consent Form I hereby consent to and authorize to perform the following procedure esthetician I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me along with the risks and hazards involved by. Although it is impossible to list every potential risk and complication I have been informed of possible benefits risks and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age skin condition and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care I will consult the esthetician immediately. I have also to the best of my knowledge given an accurate account of my medical history including all known allergies or prescription drugs or products I am currently ingesting or using topically. procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician whose signature appears below responsible for any of my conditions that were present but not disclosed at the time of this skin care procedure which may be affected by the treatment performed today. Client Name printed Client Name signature Date Esthetician Date member Associated Skin Care Professionals. Although it is impossible to list every potential risk and complication I have been informed of possible benefits risks and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age skin condition and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I also recognize there are no guaranteed results and that independent results are dependent upon age skin condition and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care I will consult the esthetician immediately. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care I will consult the esthetician immediately. I have also to the best of my knowledge given an accurate account of my medical history including all known allergies or prescription drugs or products I am currently ingesting or using topically.

Chorus consent form Note check with your alarm provider or telecommunications service provider Your signature Our authorised technician signature Name Date NDF-240 Ultra-Fast Broadband Installation Consent Form v1. 2 November 2014 Chorus End User Terms Chorus owns and provides the Chorus network over which telecommunications and data services are provided to end users including you. Reference Number Ultra-Fast Broadband Installation Consent Delivering fibre to enable ultra-fast broadband in your property Your telecommunications service provider has asked us to install fibre network equipment at your place so you can get connected to ultra-fast broadband. Before we start we would like to confirm that you understand the work required to install fibre to your property and the terms on which we will carry out the work. Your name Address for the property where installation work will happen If you are not the person who ordered the service the customer please confirm that you are authorised to represent the customer Signature you and us for as long as and whenever any of our equipment is located on property you own occupy or have control over. In particular if our network is damaged on your property you may be liable for the cost of any repairs and we may access your property in the future for the purpose of maintaining our grid* About your installation Below is a summary of the work that we have agreed to carry out to install fibre and network equipment to your property. We will need you to sign below to confirm you agree to these activities and any other work and activities that may be reasonably associated with this kind of work. Inside your dwelling Location of our fibre network equipment ONT Drilling small holes Surface mounted installation of outlets and network equipment Cutting holes in walls Integration of existing property wiring Exposed surface mounted wiring Removal of ceiling tiles Access to ceiling and under floor cavities Outside your dwelling Aerial cable Reuse existing pipe New buried cable or pipe Removal of concrete / tiling / pavement Removal of existing copper cable to house Digging of holes Clean-up we will leave the property in a clean and tidy state on completion* This does not include reinstatement for hard surfaces to guarantee colour finish or age match Other I confirm that I have seen read and understood this information and the End User Terms and accept those terms and If I am not the owner of the property I have obtained the consent of the owner for the installation works and I understand that there may be an impact on the operation of burglar and medical alarms particularly monitored alarms. Note check with your alarm provider or telecommunications service provider Your signature Our authorised technician signature Name Date NDF-240 Ultra-Fast Broadband Installation Consent Form v1. 2 November 2014 Chorus End User Terms Chorus owns and provides the Chorus network over which telecommunications and data services are provided to end users including you.

Digital consent form Patient Consent Form for Video/Digital Recording for Training Purposes Patient s name Place of Video Recording Name of person s accompanying patient to the consultation Date We are hoping to make video/digital recordings of some of the consultations between patients and Dr. whom you are seeing today. The videos are used by doctors training to be a GP to review their consultations with their trainers. The video/digital recording is ONLY of you and the doctor talking together. Intimate examinations will not be recorded and the camera will be switched off on request. All video/digital recordings are carried out according to guidelines issued by the General Medical Council and will be stored securely in line with the practice guidelines. They will be deleted within one year of the recording taking place. You do not have to agree to your consultation with the doctor being recorded* If you want the camera turned off please tell Reception - this is not a problem and will not affect your consultation in any way. But if you do not mind your consultation being recorded please sign below. Thank you very much for your help* TO BE COMPLETED BY PATIENT I have read and understood the above information and give my permission for my consultation to be video recorded* Signature of patient BEFORE CONSULTATION. Date. Signature of person accompanying patient to the consultation After seeing the doctor I am still willing/I no longer wish my consultation to be used for the above purposes. whom you are seeing today. The videos are used by doctors training to be a GP to review their consultations with their trainers. The video/digital recording is ONLY of you and the doctor talking together. Intimate examinations will not be recorded and the camera will be switched off on request. The video/digital recording is ONLY of you and the doctor talking together. Intimate examinations will not be recorded and the camera will be switched off on request. All video/digital recordings are carried out according to guidelines issued by the General Medical Council and will be stored securely in line with the practice guidelines. All video/digital recordings are carried out according to guidelines issued by the General Medical Council and will be stored securely in line with the practice guidelines. They will be deleted within one year of the recording taking place. You do not have to agree to your consultation with the doctor being recorded* If you want the camera turned off please tell Reception - this is not a problem and will not affect your consultation in any way. They will be deleted within one year of the recording taking place. You do not have to agree to your consultation with the doctor being recorded* If you want the camera turned off please tell Reception - this is not a problem and will not affect your consultation in any way. But if you do not mind your consultation being recorded please sign below. Thank you very much for your help* TO BE COMPLETED BY PATIENT I have read and understood the above information and give my permission for my consultation to be video recorded* Signature of patient BEFORE CONSULTATION.

Botoxdysport consent form / Consent Form Please initial each section to indicate that you understand each topic. Do not initial if you desire more information. Proposed Treatment Injection of a very small amount

Medication consent form 606 cm... Commonwealth of Massachusetts Department of Early Education and Care MEDICATION CONSENT FORM 606 CMR 7.11(2)(b) Name of child: Name of medication: Please one of the following: Prescription: Oral/Non-Prescription:

Hydrafacial consent form skinc... Rev. 3/18/13 CLIENT CONSULTATION AND RELEASE FORM Please read carefully, complete, sign and date this form prior to your treatment. Name: Phone: ( ) Address: City: State: Zip: Email: HYDRAFACIAL BLUE

Copper t iud consent form dhhs... Division of Public Health Women s and Children s Health Section Family Planning and Reproductive Health Unit Request and Consent for the IUD Copper T 380A

Ultherapy consent form suncoas... Swetanshu Chaudhari, MD 400 W. Parkwood Ave, Ste 116 Friendswood, TX 77546 (832) 3980112 Patient Consent Form In considering an Ultherapy treatment with the Ulthera system, please read the following

Consent child form CONSENT FOR MINOR CHILDREN TO TRAVEL Date: I (we): authorize my/our minor child(ren): to travel to: on: aboard Airline/Flight Number: and/or Cruise Ship: with: . Their expected date of return is

Letter travel form LETTER OF CONSENT FOR TRAVEL OF A MINOR CHILD Because of increasing instances of child abduction in custody cases and a growing number of children who are the victims of trafficking or pornography an immigration officer airline or travel company may ask you to provide some form of letter of consent if your child is traveling internationally with only one parent or with another adult such as a grandparent aunt uncle etc. The sample letter below is a guide only. You may also wish to have the letter of consent notarized. Last Updated 11/08 To Whom It May Concern I/We Full Name s of Custodial and/or Non-Custodial Parent s /Legal Guardian s am/are the lawful custodial parent and/or non-custodial parent s or legal guardian s of Child s full name Date of Birth Place of Birth U.S. Passport Number Date and Place of Issuance of U.S. Passport has my/our consent to travel with Full name of accompanying person U.S. or foreign passport number to visit during the period of. Name of Foreign Country Dates of Travel Departure and Return During that period will be residing with Child s Name Name of Person Who Child will be Residing With in Foreign Country Number/street address and apartment number City State/Province Country Telephone and fax numbers work cell phone and residence Signature Date Signature of Custodial Parent and/or Non-Custodial Parent or Legal Guardian Full Name Signed before me Full Name of Witness this at.

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