Fat Dissolving Treatment Consent

Fat Dissolving Treatment Consent
Please complete this form to confirm your understanding and agreement to receive fat dissolving treatment.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 Code
Do you have any allergies?
If yes, please list your allergies.
Are you currently taking any medications?
If yes, please list your current medications.
Have you had any previous cosmetic procedures?
If yes, please specify previous procedures.
I confirm that I have been informed about the nature, purpose, risks, and possible side effects of the fat dissolving treatment. I understand that results may vary and that there are no guarantees. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. By signing below, I voluntarily consent to undergo the fat dissolving treatment.
Powered by Jotform SignClear
Should be Empty: