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ProFractional Interest Form
If you would like to schedule an appointment or get more information on the ProFractional Treatment at Griffin Medical Group, Please complete the form below and someone will contact you shortly. I understand that Griffin Medical Group is offering the ProFractional Full Face Treatment at 1/2 price for four days only, and that I will be eligible for a 10% discount of the 1/2 off price if I purchase a package of 4. Treatment Dates are: March 05, 2008, April 02, 2008, May 07, 2008, and June 04, 2008. I understand that treatments are subject to appointment availability, I am also aware that there is a $250.00 reservation fee for my appointment which will be forfeited if I am unable to make my appointment.

Name:

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Allergies to Medication:

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Date of Interest for Procedure


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