Consent to Treat Form

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: Pregnancy, recent facial surgery, allergies, tendency to cold sores/fever blisters, use of topical ingredients that contain retinal, AHA's or the like, use of acne medications or other skin medications including Retin-A, Accutane, Differin, Tazorac or the like.