Consent form

Consent form
Name

First NameLast Name
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Phone Number
Please enter a valid phone number.
Email
example@example.com
Contra-indications requiring medical permission

PregnancyCardiovascular ConditionsEpilepsyDiabetesAny dysfunction of the nervous systemNone
Contra-indications that restrict treatment

Contagious or infectious diseasesHypersensitive skinBotox/dermal fillers( 1 week following treatment)SunburnSkin diseasesNone
Concerns

Sagging SkinCelluliteStretch markFine linesAcne/ Acne ScarsWrinklesPigmentationDark circlesPuffy eyesSkin TagsBelly or Body Fat (Reduction)/ Weight ManagementLibidoPelvic Floor Muscles/ Vaginal Muscles/ Erectile disfunctionTirednessOther
If Other Please specify
Do you give consent to proceed with the treatment

YesNo
Date

MonthDayYear
Date
Signature

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