Verification and Certification Form

Select the service you are going to receive

Information Confirmation:

The client certifies that the information provided in the previous form remains accurate and complete. Any changes to their health condition must be reported prior to the treatment.

Technician Review:

The assigned technician certifies that they have reviewed the client’s information and deem it safe to proceed with the treatment based on the provided details.

Compliance Certification:

This form has been created in accordance with applicable Massachusetts state regulations and ensures that the treatment will be carried out following safety and privacy standards under the law.

Client’s First name

Client’s Last name

Client’s Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Technician’s Signature:

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date picker

Verification and Certification Form

Let's Connect

SHIPPING & RETURN POLICY

PRIVACY POLICY

REFUND AND CANCELLATION

TERMS OF USE

FAQS