SOCU 2022 Patient Volunteer Application | Skin of Color Update | Dermatology Conference

SOCU 2022 Patient Volunteer Form

Name

First Last

Date of Birth

Mobile Phone

Date of Arrival to SOCU

Date of Departure to SOCU

Please tell us about any previous treatments you have received in the last 12-18 months and the dates of treatment. Please be as specific as possible (for example: neurotoxin injections for crow’s feet and please include product brand names). If you have never had any previous treatments, please let us know.

Please tell us which area(s) of your face for which you would like to receive treatment. Please be as specific as possible.

Please indicate if there are any areas of your face you do NOT want treated (i.e., I do not want to receive lip filler).

Do you have any known allergies? As part of our onsite evaluation, we will ask you about your medical history and require you to take a rapid COVID test (administered by our patient coordinator) if you are selected to be a volunteer patient.

Provide recent photos: full face, close-up of area(s) for desired treatment.

Max. file size: 8 MB.

SOCU 2022 Patient Volunteer Form

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