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Infusion Therapy Form -Form Fill

Section One
Q1

I have read and understand the pre care instructions & agree to follow those instructions*
Q2

I have read and understand the post care instructions & agree to follow those instructions*
Q3

Name*

First Name
Q4

Name*

Last Name
Q5

I grant to V.Rose Aesthetics the right to take photographs and/or videos of me immediately prior to, during, and/or after my treatment. I authorize V.Rose Aesthetics to copyright, use and publish the same in print and/or electronically. I agree that V.Rose Aesthetics and affiliates may use such photographs and/or videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.*
Q6

Signature*
Q7

Date*

Date
Q8

Please indicate areas of concern:*