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    1) Please fill in your medical history:

    Medication currently taken on a regular basis:

    Previous treatment with any of the following:

    Botulinum ToxinFillersThreadsPeels

    Specify:

    Any complications to the above?

    Susceptibiliy to keloids or scarring?
    YesNo

    Do you or anyone in your family suffer from porphyria?
    YesNo

    Are you currently on cortisone or antibiotics?
    YesNo

    Have you ever had any previous cosmetic surgery?
    YesNo

    Are you pregnant/trying to fall pregnant or breastfeeding?
    YesNo

    Are you prone to bruising?
    YesNo

    Please read the following carefully and discuss any uncertainties with us.

    Information and consent form
    1. I have been informed about alternative treatments & procedures such as cosmetic surgery, laser treatment & filler treatments.
    2. My questions regarding both procedure and contraindications were answered to my full satisfaction.
    3. 1 have received the pre- & post treatment check list
    4. I also had adequate time to consider my decision
    5. I understand that I am free to revoke my consent at any time before treatment without the need to give any reason. By placing my signature below, I declare my consent to cosmetic treatment with Botulinum Toxin.


    2) Please Fill In Covid-19 Protocol Form Below:

    Dear beloved patient

    Please complete this form and submit it with confirmation of your treatment procedure.

    I hereby give consent to the Dermatologist at CDC to perform a consultation / treatment procedure on me. I understand that CDC has strict regulations in place to limit the spread of Covid-19.

    It is of the utmost importance that you do not present any of the following:
    • Slight cold
    • Flu
    • Sore throat / cough
    • Temperature of above 37.5°C
    • Definite loss of smell and taste
    • Were in contact with anyone who tested positive for Covid-19 during the past 14 days.

    Kindly be informed of the following protocol we are currently taking at CDC:

    1. Please arrive for your appointment exactly on time.
    2. Parking is available in front of our building. Be so kind to wait in your vehicle until your treatment if you are a few minutes early. Please leave your handbag in the car and only carry a small item such as your wallet.
    3. You will be personally greeted at the door by the Dr’s assistant.
    4. Please wear your own face mask.
    5. Your temperature will be tested.
    6. The Doctor’s assistant will hand you a pair of overshoes to wear and sanitize your hands.
    7. You will be escorted to your immediate treatment room.

    Should you test positive for Covid-19 in the next 7 days, kindly inform us.

    Product sales:

    • Kindly advise your Doctor’s assistant during your appointment should you have the need to purchase any products and she will gladly get your parcel ready for you.

    Payment options:

    • Payment may be done at our practice with credit card – CDC will take the necessary measures to sterilize.
    • EFT can also be done 3 days prior to your treatment (please make sure of the exact amount and notify our reception by contacting us).
    • Unfortunately, no cash payments will be accepted at this time.

    Please know that every candle we light at CDC signifies the love and care we have for you as our patient.
    Feel free to notify us should there be anything more we can do to make you feel comfortable and safe at our practice.

    For any questions please do not hesitate to contact us: capedermteam@gmail.co.za. Follow us on Facebook and Instagram for any updates.

    View our privacy policy here

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