Name: ________________________________________________Date ____________________
I understand and agree with the following statements:
1. Treatment area(s) that will be treated and the total price.
2. Treatment outcome depends on the individual and that the outcome cannot be guaranteed due to metabolic, genetic and
3. Satisfaction will not be attainable with the end results if my expectations exceeded the possible end point outcome.
4. During the procedure and clinician may recommend further treatments to meet my satisfaction.
5. Typically, maintenance treatments are needed.
6. No show charge is $50 without 24hour notice of cancellation.