OBAGI CONSENT FORM Name Name I have been fully informed by my practitioner and understand the following conditions relating to the use of the Obagi Nu-Derm System inclusive of the Tretinoin The treatment programme has been explained and I am fully aware and committed to comply with the programme outlined by my skin practitioner. AgreeDisagree The cost of treatment has been advised and the specific treatment protocols have been discussed and established. I understand the prices quoted for my treatment programme. AgreeDisagree I understand that the individual or Bella Radiance will not be held liable for any adverse reactions as a direct or indirect result of my nondisclosure of any relevant facts or information requested during the consultation. AgreeDisagree I agree to inform Bella Radiance of any changes to my health that could affect my treatment. AgreeDisagree I understand the treatment programme is a minimum of 12-24 weeks to obtain the very best results for my skin concerns. AgreeDisagree I understand an expected time to treat my skin concerns will be outlined by my Practitioner, but may be subject to change. AgreeDisagree I am aware the the following are normal skin reactions: Redness, Dryness/Flakiness/Peeling, Skin Sensitivity, Breakouts of Spots, Tight feeling of the skin AgreeDisagree I have been fully informed of all normal skin reactions that can occur during the initial reactive phase of treatment. These reactions can last throughout the whole process depending on the individual skin concerns and I have been advised on how to deal with all of these normal skin reactions. AgreeDisagree I agree to attend regular 6 weekly assessments to monitor the changes in my skin and to discuss my progress to ensure my individual needs for my skin are addressed. AgreeDisagree I am aware that although Obagi is able to address a vast majority of my skin concerns there may be other treatments offered at Bella Radiance alongside the use of the products to obtain the very best results for my skin AgreeDisagree I understand that my treatment will be fully documented through out and photos will be taken on a regular basis to monitor my progress. A pre treatment photograph will be required. AgreeDisagree Bella Radiance may use any of my photographs for marketing, promotional or educational purposes. Although photographs will not contain my name or any other identifying information I am aware that I may, or may not, be identified by the photographs. I DO give permission for my photographs to be usedI DO NOT give permission for my photographs to be used Bella Radiance has provided me with information on all known possible side effects to enable me to make an informed choice whether to commence treatment. I understand that (clinic) cannot be held responsible for anyunknown side effects which, although unlikely may occur as a result of using Obagi. AgreeDisagree I understand that all of the information I have given is confidential and protected under the Data Protection Act and will not be released to a third party. AgreeDisagree Upload Pre Treatment Photograph Here By submitting this form, you agree that you are above the age of 18, and fully understand the questions asked above, answering truthfully throughout.