Radiofrequency Treatment Consent Form
Please complete this form to provide your informed consent for radiofrequency treatment. Your information will remain confidential.
Patient 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 have any known allergies?
*
No known allergies
Yes (please specify)
Are you currently taking any medications?
*
No
Yes (please list)
Do you have any of the following conditions? (Select all that apply)
*
Pacemaker or implanted electronic device
Pregnant or breastfeeding
Active skin infection in treatment area
Skin cancer in treatment area
None of the above
Other (please specify)
Area(s) to be treated with radiofrequency
*
Signature (Please sign below to confirm your consent)
*
Submit Consent
Submit Consent
Should be Empty: