for professional use only


I have read and answered the questionnaire honestly.

I agree that this is a complete disclosure that overrides any prior oral or written disclosures.

I understand that withholding information or providing false information may result in treatment contraindications and/or skin discomfort.

I understand that it is my obligation to keep the practitioner up to date on my current medical or health conditions.

I understand that the services provided are not intended to be a substitute for medical treatment, and that any information provided by the practitioner is intended to be instructive rather than diagnostically prescriptive.

I realize that the information provided above is strictly confidential and is intended to assist the practitioner in providing better service.

I confirm that I give_____________ (therapist) my consent to carry out the treatment we have discussed and hold_________ (therapist) and the company harmless from liability that may result from this treatment.

The information given is correct and to the best of my knowledge. I will follow the verbal and written aftercare advice given to me.

form 5
form 6