The undersigned, certify that the above information is correct and acknowledge that failure to disclose any facts in relation to this form leads to the invalidity and cancellation of the document. And if any changes are made in health conditions after signing this declaration, the clinic must be notified immediately, Also The undersigned, authorize the Padra Clinic and the medical staff to perform a hair transplant for me and acknowledge the following:
1. The doctor explained to me the nature of the operation and the instructions before and after the operation and possible side effects such as bleeding, allergies inflammation or swelling or some headaches after the operation. All my queries and future expectations for hair transplantation have been explained. I agree and am convinced of what has been explained to me, and therefore I agree to hair transplantation at Padra Clinic at my full personal responsibility without the slightest responsibility for the clinic.
2. In case of any side effects after transplantation, I undertake to see the doctor’s clinic without delay to avoid any future medical problems.
3. I undertake to abide by the instructions given to me by the medical staff of the post-transplantation period, such as smoking, drinking coffee, washing hair, sports, covering the hair or dealing cruelty or the like .
4. Therefore, I acknowledge that if the operation is cancelled by me or I didn’t attend on the specified date, half of the total cost of the agreed operation will be deducted, and it is not permissible to claim this amount amicably or legally. I also, the undersigned, acknowledge If I canceled the operation before three days, a twenty percent will be deducted from its value of the total agreed cost for the operation.
5. I have been informed by the medical staff that the follicles extracted from the donor area (back) do not return again after transplantation, so I am aware that the donor area will reduce hair density after transplantation, especially if the patient has already transplanted hair before
6. I agree to photograph the planting area before and after planting by the officials of the clinic to confirm an improvement or not after transplantation. The clinic undertakes to maintain the confidentiality of photos and information and not to display them in any social media only after the written consent of me.
7. My signature on the authorization is my acknowledgment of consent to the transplant procedure and I understand the complications and side effects that may occur during or after transplantation which may cause not grow hair and agree to the procedure proposed by the medical staff to treat these complications.
In case of emergency mention two names to be contacted
