Broad Band Light Consent Form
If you are interested in getting BBL treatment, please fill out and submit this consent form, fitzpatrick skin type form, and medical history form. All of these forms are located at the "Forms" tab on the website. (g2jclinic.com) Filling out and submitting all these forms before coming to the office will waive the $250 consultation fee.

G2J Clinic Inc,
5150 Graves Ave. San Jose, CA 95129
408-253-8000
g2jclinic.com

Name *
Your answer
Date of Birth *
Your answer
Email or Phone number *
Your answer
Please mark the checkboxes as you read the form to show you have understood each sentence
If you have any questions, please ask the doctor during the office visit for any clarifications.
Broad Band Light (BBL) *
Required
Possible side effects and complications of BBL treatment *
Required
I acknowledge that I have read and understand “Information/Instructions of BBL Treatment” and this foregoing “BBL Informed Consent Form”, and I feel I have been adequately informed of the risks of BBL therapy as well as alternate methods of treatment. *
Please write your name and date down below to serve as a signature. You will be asked to write your signature at the office again to verify.
Your answer
I do not give permission for photos and other audio-visual / graphic materials (which will belong to the physician) to be used by the physician or Sciton, Inc. for educational, marketing and/or scientific purposes. Although the photos 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 have read and understand this agreement and all of my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement.
Please write your name and date down below to serve as a signature. You will be asked to write your signature at the office again to verify.
Your answer
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