Facial Consent Form

Please take a moment to fill out the form.

First and Last Name

Phone

Date of Birth

Please explain any questions or concerns

If yes please explain why

By signing below I acknowledge that I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contradictions to the requested treatment, and agree that I do not have any conditions that would make the requested treatment unsuitable.

By signing below I acknowledge that I will inform the technician of any discomfort I may experience at anytime during my treatment to allow them to adjust accordingly. I agree to waive all liabilities towards my technician and employer for any injury or damages incurred due to misrepresentation of my health history.

Thanks for submitting!