Microcurrent Facial Consent Form
Please complete this form to provide your health information and consent for microcurrent facial 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
Do you have any of the following? (Select all that apply)
*
Pacemaker
Epilepsy
Pregnancy
Metal implants
None of the above
Do you have any known allergies? If yes, please specify.
Are you currently taking any medications? If yes, please list them.
Do you have any skin conditions or concerns?
Emergency Contact Name and Phone Number
*
Signature
*
Submit Consent
Submit Consent
Should be Empty: