MOXI informed consent I authorize Perpetual Aesthetics and Wellness, to perform MOXI treatments on the following area(s) of my body: Area(s) of treatment * Face Neck Declottee 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) and ephelides (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. * I understand that the treatment by the Sciton Moxi system involves payment, and the fee structure has been fully explained to me. * I also understand that there are other options for treatment that are available and each of these other options has 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. Yes No * Consent to allow the photographs to be used in presentations or publications including marketing, but not limited to, use by SGK Plastic Surgery, or Sciton Inc. to further education and inform others about Moxi treatments. Yes No * 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. First Name Last Name Date * MM DD YYYY Email * Thank you!
