C&D Digital Signatures
Follow Up Medical Form
Date of Treatment (Select)
(Required)
DD slash MM slash YYYY
Email
(Required)
Name
(Required)
First
Last
Since your last visit do any of the following statements apply to you:
Have you had any changes to your medication
(Required)
Yes
No
Have you had any changes in your medical history
(Required)
Yes
No
Have you developed any new medical conditions
(Required)
Yes
No
Have you had any recent treatments or surgeries
(Required)
Yes
No
Have you had any sun exposure in the past 4-6 weeks including sun beds
(Required)
Yes
No
Do you currently have any fake tan or tanning lotions in the area being treated
(Required)
Yes
No
If you have answered yes to any of the above questions, please include all details here:
I have answered the above questions honestly and consent to proceeding with my laser treatment today.
(Required)
* I have answered the above questions honestly and consent to proceeding with my laser treatment today.
Additional notes:
Please leave for the Cloak & Dagger team to add any relevant information.
Digital Legal Consent
(Required)
Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures
Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or "wet ink" signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.
You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the "sending party" and withdraw your consent at any time, as described below.
Scope of Consent
By utilising this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the "sending party." You may withdraw your consent, at any time, by following the procedures outlined below.
Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the "sending party" by following the procedures outlined below. The "sending party" may apply a charge for additional expenses incurred by printing and mailing paper copies.
Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the "sending party" that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.
Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the "sending party" directly; by telephone, by email (sent to the "sending party" with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.
"Withdrawal of Consent To Transact Business Electronically" To allow the "sending party" to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.
"Requesting A Paper Copy" To allow the "sending party" to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .
"Update Your Contact Information" To allow the "sending party" to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.
The "sending party" will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.
I agree to the terms and conditions.
Signed
(Required)
Admin Verification
(Required)
Please hand the tablet/laptop to the Cloak & Dagger team member for them to check all your details before finalising the form.
