Collagen Induction Facial Consent Form
Please provide your information, review the health screening, and acknowledge your consent for the collagen induction facial procedure.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any of the following skin conditions? (Check all that apply)
*
Active acne or breakouts
Eczema or psoriasis
Open wounds or sores
None of the above
Other (please specify)
Are you currently taking any medications or have allergies? Please list them below.
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
*
Submit Consent
Submit Consent
Should be Empty: