Medical Spa Testimonial and Marketing Consent Authorization Form
Please complete this Medical Spa Testimonial and Marketing Consent Authorization Form to provide your testimonial and grant permission for its use in our marketing materials.
Full Name
*
First Name
Last Name
Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Service Received
*
Please Select
Facial Treatment
Laser Therapy
Injectables
Body Contouring
Other
Your Testimonial
*
I consent to the use of my testimonial in marketing materials.
*
Yes, I consent
No, I do not consent
I grant permission to use my name and image/likeness in marketing materials.
*
Yes, I grant permission
No, I do not grant permission
Preferred Marketing Channels for Publication
*
Website
Social Media
Print Materials
Email Newsletters
Other
Submit
Should be Empty: