Patient Information Form

Full Name *

Email *

Your Phone *

Address

Street Address *

City *

State *

Country *

Postal code *

Select the services or treatments you're interested in: *

Weight Loss Programs

Aesthetic Treatments

Flexible financing options to make your desired treatments more accessible

Photo & Video Consent

We would like your permission to use photo(s) and/or video(s) for advertising. Your photo(s) and/or video(s) will be used without identifying your name or personal information.

The consent includes the use of photos/videos for educational purposes, including but not limited to:

Instruction & training
Display to professional organizations
Websites & social media
Marketing & advertising

This consent will apply to all past, present, and future procedures, unless we receive a written request from you to discontinue use. (A 60-day written notice is required to revoke consent).

Acknowledgment

I give RAPHA Aesthetic and Weight Loss permission to use my photo(s) or video(s) as stated above. Please select one option below: *

Full Face

Skin Area Treated ONLY

I do NOT agree to have my picture taken

Signature *

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Disclaimer: Photos and/or videos will be used responsibly and solely for the purposes stated above. No compensation will be provided for the use of these materials.

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