Lamprobe Consent Form

LAMPROBE Treatment Consent Form

Maison de Peau, LLC.
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Maison de Peau's representative has explained to me that the LAMPROBE processes are popular and effective for the cosmetic treatment of many minor superficial skin irregularities. I consent to have the LAMPROBE utilized on me for the cosmetic treatment of:
List of Skin Irregularities to be treated:
Risks associated with the LAMPROBE treatment even though minimal but it can happen. The risks include burn/scabbing, skin discoloration and scarring. It is extremely important to follow home care advice to avoid scarring. In consenting to having the LAMPROBE performed on me, I hereby release and forever discharge the performing practitioner of said cosmetic treatment and Maison de Peau, its officers, employees and /or associated subcontractors, manufacturers, distributors and suppliers of an from all claims, demands, damages action or cause of action arising out of the performance of the said cosmetic treatment procedures.
Maison de Peau regularly documents the demonstration and use of the LAMPROBE using before & after photos and/or videos. I understand that all of the photos taken will be the property of Maison de Peau and may be used or shared at a later date for educational and/or marketing puroses and I conset to this use.

I have read and agreed to the above conditions.
Signature *

Clear
Should be Empty:

LAMPROBE Treatment Consent Form