Name *

First Name

Last Name

Phone

(###)

###

####

We have monitored your skin-clearing journey through photo documentation. I, the undersigned do hereby agree to the following. I am allowing Sara of Mansfield Hollow Skincare LLC, to take photos of my treatment and/or treated areas to be used for the purpose of monitoring my progress. *

I request my photos be used in the following ways:

I give permission for my photos to be used for education

I give permission for my photos to be used on social media and/or Mansfield Hollow Skincare, LLC's website.

At my request, my identity will remain anonymous.

At my request, my photos will only be used for my chart and will not be shared.

Is it okay to share your words about your experience on my website and/or social media? *

Check all that Apply:

Yes

No

Yes, but I would like to remain anonymous.

Date *

MM

DD

YYYY