Microcurrent Therapy Consent Form
Please complete this form before your microcurrent therapy session so the provider can review your details, treatment goals, and consent to proceed.
Client Information
Client Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Session and Treatment Details
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treatment Area(s)
*
Face
Neck
Décolletage
Jawline
Forehead
Under Eyes
Body
Other
Main Reason for Treatment / Concern
*
Health Screening and Consent
Health considerations or contraindications
*
Pregnancy
Pacemaker or implanted electronic device
History of seizures
Skin irritation or open wounds
Recent surgery or medical procedure
Cancer or active medical treatment
Metal implants or piercings in treatment area
None of the above
Current medications or topical products
Emergency contact name and phone
*
Submit
Should be Empty: