ABSTRACT
If I have any questions concerning my treatment, I may call the Phototherapy Treatment Center. --------------------------------------------------------------------------- I have fully read and fully understand the above information concerning scalp treatments. I realize that these treatments may not cure my skin disorder. I have been advised of the most frequent risks and consequences of scalp treatments and of the alternative treatments available to me. Even with this information I elect to proceed with scalp treatments. I authorize my doctor to prescribe scalp treatments. This authorization extends to his associates, including other physicians and assistants selected by him/her to carry out the treatments. I understand I am free to withdraw my consent and stop treatment at any time.
