Success Story Consent Information

Please note: the following is an example of the Success Stories Consent Form used by The Belgravia Centre and is for information purposes only.


Belgravia Centre Success Stories Consent Form Header

We are thrilled that you are happy with our service and would like to provide a review and photos for our online Success Stories webpages: Thank you for providing your comments in our comment book or via one of our social media channels.

Please complete this form to confirm your consent to The Belgravia Centre using your personal information for the purpose of advertising our products and services on our online and social media channels, as described below.

Your details: please complete

Your full name              Please note, we will not publish your name in your Success Story

Treatment advisor

Photos                             []      I have seen my before and after photos and consent to their use (tick to confirm)

Social Media                  By completing this form, you consent to us posting your Success Story on our website.

[]        I also consent to The Belgravia Centre using my Success Story on its social media channels, inclulding Facebook, Instagram and Twitter (tick to confirm)

IMPORTANT: Please read

How we will use your Success Story: We keep our Success Stories online indefinitely, as we find this provides a valuable benefit to customers, helping them see the results they may achieve with our services.
We cannot control the information you publish on social media (including Facebook and Instagram). However, we will not publish your name and we blur all faces on photos published in the success stories on our own websites.

Please note that we include the following treatment information on our success stories: your age (by decade, e.g. 40s); your sex; your diagnosis (e.g. Male Pattern Hair Loss, Diffuse Thinning) the level of your hair loss before treatment; the level of regrowth during treatment; pattern of hair loss (e.g. generally thinning all over); and the source of your review (e.g. handwritten at clinic, email, Facebook, Twitter).

Your rights to withdraw consent: 

Your consent is voluntarily given and you are under no obligation to consent. Even if you consent, you can subsequently withdraw consent at any time and we will remove your success story from our online and social media channels. If you wish to withdraw your consent, please contact your treatment advisor or email, providing your full name. This will not affect our use of your personal information for other permitted purposes as described in our Privacy Policy, available at

Thank you! We like to provide happy clients who provide positive reviews with a token thank you gift. Please note that if you do not consent, or if you subsequently withdraw consent before we have dispatched your thank you gift, you may not receive a thank you gift.

How we protect your personal information: For further information about how we protect your personal information and how you may exercise your data protection rights, please see our Privacy Policy.
You can find our Privacy Policy online at, or please see the copy which was provided to you previously (e.g. when you completed your initial Patient Information Form).

By signing below, I confirm that I consent to the uses of my personal information as described in the consent form.

Signed:                                                                                     Date: