Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all information detailed below * *

This applies to the area that you plan to have treated

I do not have photo-sensitivity

I am not prone to epilepsy/seizures

I do not have active cold sores

I am have a sunburn

I do not have malignant skin tumors

I am not going under cancer therapy (chemotherapy/radiation)

I have not received cortisone or steroid injections within 5 days

I have not used prescription retinoids (Tretinoin, Retin-A etc.) within 7 days

I have not receved botox/fillers/injectibles within 2 weeks

I have not used Accutane within 6 months

I am not pregnant

Date *

MM

DD

YYYY