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Esthetician Consultation Forms - Beauty Salon Solution_edited.png

MOXI Laser informed Consent

Birthday

I understand that the Sciton Moxi is intended for the treatment of actinic keratosis, and treatment of benign pigmented lesions such as, but not limited to lentigos (age spots), solar lentigos (sun spots) andephelides(freckles), and other dermatological conditions and that clinical results may vary in different skin types.  I understand that as with any similar type of treatment there is a possibility of rare side effects such as scarring and permanent discoloration as well as short term effects such as reddening, mild burning, and temporary discoloration of the skin.  These effects have all been fully explained to me.

Photography

Consent to photographs and other audio-visual and graphic materials before, during, and after the course of my therapy to be used for medical, marketing, and education purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

I also allow photographs to be used in presentations or publications including marketing, but not limited to, use by Sciton Inc. to further education and inform others about Moxi treatments.

I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all of my questions answered to my satisfaction. I understand the procedure and accept the risks. I agree to the terms of this agreement.

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