SkinPen Patient Consent Form

(Aesthetics)

Date:

Patient Information

• Patient Name: {{patient_first_name}} {{patient_last_name}}
• Date of Birth: {{patient_birthdate}}

Treatment Information

I understand that I will be receiving SkinPen microneedling treatment, which uses fine needles to create controlled micro-injuries to stimulate the body's natural wound healing process and collagen production.

Consent Statements

Please initial each statement:

1. I understand the nature of SkinPen microneedling treatment.

2. I understand the potential risks and benefits.

3. I have been informed of alternative treatments.

4. I understand that results are not guaranteed.

5. I will follow all post-treatment instructions.

Signatures

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.

Form Complete

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

SkinPen Patient Consent Form

Unique Document ID: b91029134441525e3fc1881cbb0041f9f235aa34

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Timestamp	Audit
December 31, 1969 7:00 pm UTC	Document Uploaded by ENNU - ennu-appointments@ennu.co IP:

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