*THE TREATMENT: I understand and consent to having my eyes closed and covered for the
duration of the 60 - 120 minutes procedure. I understand that I will have instruments, tapes, cleansers, gel eye
pads, adhesives, and removers used that may irritate my eyes, causing them to water and blink to excess
preventing proper application and/or may be required for a removal and/or a physician’s follow-up care may be
needed.