VERSA INTENSE PULSED LIGHT INFORMED CONSENT BOOKLET
Patient Initials
Patient Initials
Patient Initials
Consent for Procedure and/or Treatment
I CONSENT TO THE PROCEDURE AND/OR TREATMENT AND THE ABOVE LISTED ITEMS (1-9).
I AM SATISFIED WITH THE EXPLANATION.
Print Full Name
*
WITNESS
*
Date
-
Month
-
Day
Year
Date
Signature
Clear
Submit
Should be Empty: