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.