INFORMED CONSENT AESTHETIC MEDICAL TREATMENT

I, ________________________________________, identified with National Identity Document

______________________ AUTORIZED to the Doctor ---------------------------------with Membership Number for the
practice of Aesthetic Medicine, in accordance with the provisions of Law 41/2002, the basic regulator of patient
autonomy and rights and obligations in the field of information and clinical documentation, so that it can be carried
out in person. , aesthetic treatment/s according to the following:

TREATMENT TYPE PROCEDURES EQUIPMENT PURPOSE

BE ON RECORD
That she/he has been duly advised and guided. All the questions she/he has asked about all the procedure(s)
have been answered satisfactorily.

CONFIRM
That the effect and nature of the procedure(s) that will be performed have been explained in detail, in
understandable and simple words; as well as its mechanisms of application, action, side effects, contraindications
or possible risks or complications and the discomfort that may be felt, even if you have a normal post-treatment
period and that the products that you have been given have been detailed in the same terms. will apply within the
treatment(s).

Likewise, YOU ADMIT, ACCEPT AND DECLARE that YOU UNDERSTAND that aesthetic processes are not an
exact science and that no one can guarantee absolute perfection, so the obligation of whoever participates in your
care to develop the procedure(s) that correspond to the treatment(s) chosen will always be about means and not
about results.

EXPRESSES THAT YOU ARE COMMITED TO:

1) faithfully follow, to the best of your ability, the medical instructions and recommendations given before, during
and after the requested treatment(s).
2) provide the necessary information for the purposes of preparing the clinical record
3) do not omit or alter any personal data neither clinical or surgical history.
YOU EXPRESS your consent that you do not suffer from any of the following contraindications:

PREGNANCY YES NO

HIGH BLOOD PRESURRE YES NO

UNBALACED HEART FAILURE, PACEMAKER OR YES NO

OTHER ELECTRICAL DEVICES
THROMBOSIS, THROMBOPHLEBITIS OR YES NO
ACTIVE BLEEDING
DIABETES YES NO

CANCER ,TUMOUR YES NO

ALERGIES YES NO

DERMATITIS YES NO

EPILEPSY YES NO

MYCOSIS YES NO

ISCHEMIA YES NO

YES NO

YES NO

YES NO

YES NO

You CERTIFY that regarding the veracity of the personal and clinical data reported in general and, especially,
those referred to in the previous table, you ACCEPT the civil and criminal liability that assists you for omission or
erroneous statement regarding your real state of health that was set out in the previous section.

Finally, YOU REFER to having fully understood this CONSENT DOCUMENT and reaffirm it in each and every one
of its points, signing at the bottom in agreement.

PATIENT’S SIGNATURE DOCTOR’S SIGNATURE

ID: Foreigner Identity Number:
DATE: