VI Peel Consent Form | Waxed By Nic

First name

Last name

Email

Phone

Brainstorm (List All Patient Concerns)

Patient Expectations

Allergies or Current Medications (List all accordingly)

Fitzpatrick Skin Type (Select Best Description)

TYPE I- Very pale skin that always burns and never tans

TYPE II- Fair skin that burns easily and tans poorly

TYPE III- Darker white skin that tans after initially burning

TYPE IV- Light brown skin that burns minimally and tans easily

TYPE V- Brown skin that rarely burns and tans darkly easily

TYPE VI- Dark brown or black skin that never burns and always tans darkly

I give full authorization to my provider and agree to all terms and conditions.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.