MOJO COSMETIC CLINIC QUESTIONNAIRE

Have you ever experienced any of the following?

Have you ever been diagnosed with any of the following?

Skincare Routine, please include both AM and PM:

General Acknowledgement & Consent Form

We require your consent to collect personal information and health information about you. Please read this information carefully, and sign were indicated below.

We collect information from you for the primary purpose of providing you with our healthcare services. We require you to provide us with your personal and health information and your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:

• To appropriately manage our practice, including undergoing conduction audits and accreditation processes, managing billing and training staff.

I understand and agree to these terms:

• I voluntarily request my physician Dr. Mackey and such associates, technical assistants, and other health care providers she may deem necessary to treat my condition.
• I understand that my physician can discover other or different conditions which require additional or different treatments/procedures than those planned. I authorise my physician, and such associates, technical assistant, and other health care providers to perform or recommend these that is advisable in their professional judgement.
• I understand that no warranty or guarantee has been made to me as to result or cure. Realistic expectations are 30% - 50% chance of improvements. Some patients have greater improvement, and some have no appreciable improvement.
• I understand that there are risks and hazards to performing medical/cosmetic treatment and procedures such as infection, bleeding, allergic reaction, bruising, inflammatory response, haematoma formation or other.

For almost all patients, clinical photography will be taken to assist in your care. This includes before and after photos/videos in the clinic and may include intraoperative photos/videos during surgery.

By signing this form, you provide permission for these images to become part of your confidential medical records.

We also would like to ask you for permission to use these photos/videos for educational purposes in addition to their use as part of your medical care. Names are not used and as far as possible, identifying factors are masked.

These photos are extremely helpful in teaching other doctors and helping other patients make an informed decision about their surgery, as you may have found yourself when researching your procedure.

We are very grateful to those patients who permit us to share their images, and we can de-identify them if you wish - however, you are under no obligation to agree to this.

Do you consent to before and after clinical photos being used, for the following:

• For the purpose of teaching other health professionals such as doctors, nurses and associated students?
  Yes

  No
• In publications e.g. social media or articles in medical journals?
  Yes

  No
• To educate other patients in clinic and online?
  Yes

  No

Declaration: I grant permission for photographs of me to be used in the formats indicated above. I represent that I am at least 18 years of age, I have read and understood the foregoing statement, and I am competent to execute this agreement.