Stretch Mark / Scar Waiver

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Name *

First

Last

Date of Birth *

Email *

Photo ID / Drivers License *

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Medical History (check all that apply)

If you clicked yes to any of the above, please describe below:

Allergies & Contradictions (Check all that Apply)

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WAIVER OF LIABILITY

Permission to use Pictures

Care and Maintenance

Known Medical Conditions/Informed Consent:

Payments & Quotations

Contradictions

Acknowledgement & Signitures

Aftercare

WHAT TO EXPECT

Date / Time *

Date

Time