VI Peel Informed Consent

(Aesthetics)

Date:

Patient Information

• Patient Name:
• Date of Birth: Patient DOB

Consent Statement

I acknowledge that I have read and understand the information provided about this treatment/service. I have been given the opportunity to ask questions and all my questions have been answered to my satisfaction.

I agree to the terms and conditions described above

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

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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

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Signature Certificate

VI Peel Informed Consent

Unique Document ID: f0c536c084b60923806e582f63d6827fe0bb40b6

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