GENERAL CONSENT FOR TREATMENT

The following is to confirm that we have discussed with you the nature of your condition, the proposed treatment
thereof, the prospects for success and limited risks of potential side effects to be performed by the physicians, nurses and
any other health care providers in American Aesthetic Medical Center. I understand that I have the right to
withhold/withdraw my consent and take full responsibilities of consequences associated with such treatment/s. As per
current medical knowledge any potential side effects resulting from our treatments are reversible and temporary in
nature.

By signing this form, you confirm and consent to the following:

1. My medical condition and the proposed treatment have been explained to me. I have been advised that although
good results are expected, the possibility and nature of complications cannot be accurately anticipated and
therefore, there can be no guarantee, either expressed or implied as to the success or other result of treatment.
2. The Potential side-effects of the treatment being idiosyncratic reactions (reactions specific to an individual), such
as: bruising, temporary pain and itching, redness, infection, onset of herpes, onset of acne, burning and
blistering, fat necrosis, facial nerve affection, unsatisfactory cosmetic result, extrusion, swelling, transient skin
discoloration, allergic reaction and reversible brow or eyelid ptosis have been explained to me.
Sun exposure, tanning beds, sunless tanning lotions and tanning creams can cause discoloration or reaction to
cosmetics or laser treatment during and after the procedure. Having any kind of tan prior to therapy or soon after
result in an increased chance of blistering permanent or temporary discoloration, scarring and discomfort. I
understand that avoidance of any UV exposure 1 month prior and 2 weeks after treatment to help alleviate some
of these discomforts. Multiple treatments will be necessary to achieve complete satisfaction.
3. I declare that while completing the medical questionnaire, I have answered the information related to my
personal medical history questions completely and I have not withheld any information.
4. I have consulted with the physician or therapist (depending on the nature of treatment) who will be treating me
and all my questions concerning the treatment have been answered to my satisfaction. I fully understand all the
above and thereafter. I consent to the proposed treatment/s: (Please initial all that apply)

Peels / MDA Vascular Lesions Laser Botox

Other Treatment/s: ______________________________________

5. Financial Consent: I understand that the medical expenses may vary according to the treatment offered. I the
undersigned upon myself to pay all the expenses that may originate from any treatment in American Aesthetic
Medical Center and its affiliated satellites. I agree to pay the full amount and acknowledge that the amount paid
by me is not refundable, cannot be exchanged for a different treatment not given / transferred to another
patient.
6. Personal Belongings: I understand that the American Aesthetic Medical Center or any of its staff accepts no
liability for loss or any damage that may occur to my personal belongings and valuables. It is my responsibility to
have any valuables and personal belongings safeguarded.
7. Clinical Research: I grant permission to my medical data to be used for clinical research if needed, with the
understanding that my identity shall remain confidential and privacy respected.
 8. Legal Provision: I understand that this form can be used as legal evidence in a court of law in case of non-
payment. I acknowledge that this consent is subject to the laws and jurisdiction of UAE.I have read the Patients’
Rights & Responsibilities displayed in the medical center.

_____________________________________ _________________/____________
Patient Name & Signature Date & Time

_____________________________________ _________________/____________
Physician Name & Signature Date & Time

WITNESS

I, _____________________________ an American Aesthetic Medical Center Employee who is not the patient’s physician
or authorised health care provider and I have witnessed the patient or his / her substitute consent giver voluntarily
signed the form.

________________________ _______________________
Name, Designation of Witness Date & Time

INTERPRETER / TRANSLATOR

To be signed by interpreter/translator if the patient required such assistance. To the best of my knowledge, the
patient understand what was interpreted/translated and voluntarily signed this form.

________________________ _______________________
Name, Title, Designation of Translator Date & Time
Guidelines for Consent Giver

1. Patient guardian or substitute consent giver must meet the following criteria
Shall be 18 years old or more. A father or mother has the right to sign on behalf of their son or daughter
regardless of their age. Shall be of sound mind and body. Shall be able to understand the content of the
declaration & sign it. Can read and write properly, otherwise may be assisted by another person who explains
the contents and sign the declaration with him/her as witness. Both male & females are considered equal in
consenting.
2. Definition of the guardian:
An adult relative who has substantial personal involvement with the patient in preceding 12 months. The
sequence of priority is: Father, Mother, Brother, Sister, Uncle (from father’s side then from mother’s side),
Grandfather, Grandmother, Other relatives from father’s side then relatives from mother’s side. If the patient
if married female, the husband is prior to the father.
3. Definition of Substitute Consent Giver:
If the patient has no relatives residing in UAE: his/her sponsor or substitute of the sponsor, then a friend may
sign on his/her behalf.
4. Exemptions:
An unconscious/incompetent emergency patient who has no guardian or substitute consent giver at home at
the time he/she is admitted to the accident & emergency unit shall be exempted from giving consent.
Husband must sign in person the declaration related to treatments and surgical interventions that may affect
his wife’s fertility in the future.
5. Only the UAE laws shall be applied to any dispute that may arise regarding the treatment or dealing with the
patient. The UAE courts are exclusively competent to decide and judge on such dispute.
6. Information & Question:
Members of the medical team should and answer patients / guardian’s / substitute consent giver’s question
in simple, easy to understand and objective manner without exaggerations or promises. The aim is to give
them enough information on all aspects of the disease, diagnostic measures and treatments, as well as any
side effects and usual complications. This should clear, scientific, easily understood, and enough to assist
him/her in taking decision. This information shall not contain any promises or expectations.
7. Language:
There should be a common language between the patient, guardian or substitute consent givers and
physician in order to understand the consent of the declaration. A translator may be used if necessary and
wherever possible, who must also sign the declaration.