High-Frequency Skin Treatment Consent Form
Please provide your information, review the treatment details, and complete the consent to proceed with your high-frequency skin treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently have any of the following conditions? (Select all that apply)
*
Pacemaker or other implanted medical device
Epilepsy or seizure disorders
Pregnancy or nursing
Active skin infections or open wounds
Metal implants in the treatment area
None of the above
Other
Are you currently taking any medications or using topical products on your skin? Please list them.
Do you have any allergies (including to skincare products or ingredients)? If yes, please specify.
Please read the following information and acknowledge your understanding before proceeding with the treatment. High-frequency skin treatments use electrical currents to treat various skin concerns. While generally considered safe, possible side effects include temporary redness, tingling, or mild discomfort. This treatment is not recommended for individuals with certain health conditions or implanted medical devices. Please inform your provider of any concerns.
Signature (please sign below to confirm your consent)
*
Submit Consent
Submit Consent
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