Photofacial Treatment Consent Form

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Have you had photofacial or similar treatments before?

Please list any allergies or sensitivities (including to medications or skincare products):

Are you currently taking any medications? If yes, please list them:

Do you have any of the following conditions? (Select all that apply)

Treatment Area(s) Requested

Emergency Contact Name and Phone Number

Signature (please sign below to confirm your consent)