Please fill out and submit the Consent Form below which enables us to treat you.

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First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Email Address*
Do any of the following conditions relate to you? Please tick the appropriate box.

Roaccutane or Accutane within the last 6 months:
Allergy to shellfish:
Allergy to asprin or honey:
Any other allergies/intolerances? Please specify:
Autoimmune disorders (HIV, Lupus, Hepatitis, etc.):
Cancer or history of cancer; Please specify:
Cold sores within the last month:
Cosmetic injections within the last 2 weeks:
Recent laser procedures in the treatment area:
Recent deep chemical peels in the treatment area:
Facial waxing with last 2 weeks:
Retin A or Retinol products:
Active eczema on the treatment site:
Open wounds on the treatment site:
Fresh scars on the treatment site:
This section of medical conditions can be treated with lower vacuum settings and without the LED light for patients on light sensitive medication and with epilepsy.
Blood thinners:
Cortisone or steroid injections:
Light sensitive medication:
Please specify here any other medical conditions we may need to be aware of:
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I consent to the use of my before, during and after facial procedure photos for education and promotional purpose:
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