Name * First Name Last Name Email * Phone (###) ### #### Do you have any of the following: Active bacterial, viral, fungal or herpetic infection Open wounds Pre-existing inflammatory dermatosis (psoriasis, atopic dermatitis, pemphigus, etc.) Skin cancer, without being cancer free for a period of 3 years and direct written notice from physician Pregnancy or nursing History of drugs with photo-sensitizing potential Use of Accutane within the last 6 -8 months Underwent any kind of surgery and not fully recovered Yes No If chosen will you be able to: Come to the office for 4 consecutive treatments every 7-10 days? Consent to use of your photographs and videos of your treatment (pre, during and post)? Use only the recommended skincare for post procedure? Yes No Thank you! We will be in touch soon to announce the winner of our first Model Call! SWS MODEL CALL SWS MODEL CALL SWS MODEL CALL
