GENERAL CONSENT FORM AND INFORMATION FOR FACIAL (BODY) /PEELING/SKIN

RESURFACING OR OTHER SKIN TREATMENTS AND POCEDURES

Prior to receiving my treatments: I understand the goal of a facial or body skin treatments as in any cosmetic
procedure, is improvement, not perfection. I understand that my results may not be perfect.

CONTRAINDICATIONS:

The contraindications to this procedure are pregnancy (if so, consult your physician prior to treatment), recent
facial surgery, allergies, cold sores/ fever blisters, use of Retin-A, Accutane (for the last 6 month) or any other
medical prescriptions and other health issues.

RISKS AND COMPLICATIONS:

Common potential side effects are: dryness, sensitivity, tiny scabs (where older acne impactions were removed),
flaking, superficial temporary dark spots, mild bruising, scarring, crusting, itching, redness, infection, swelling,
onset of acne, burning and blistering, or any other unsatisfactory cosmetic results ( reactions specific to an
individual ) are normal and temporary. Thus, sensitivity test for product or chemical peels is essential for safe
procedures which will be done before performing the treatment.

Have not had any chemical peel of any kind (laser or other cosmetics procedures), within 14 (may vary) days prior
the treatment. I understand I cannot have another treatment within 14 days (may vary) after my treatment
whether it is performed at this location or any other location.

By signing this form, you confirm and consent to the following:

I have been truthful in revealing any condition that may be contraindicated to this procedure.

I have been explained that the common potential side effects.

I have not had any chemical peel of any kind (laser or other cosmetics procedures), within 14 (may vary) days
prior the treatment.

I understand if any Allergic Reactions: Call the Emergency or Doctor immediately, and temporarily discontinue
your products.  Rub ice cubes on the skin in a circular motion for two minutes every hour, pat dry, and apply cold
compresses. Allergy is rare and symptoms usually disappear in a day or wo. Inform your Therapist (clinic).

I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age,
condition of skin, sun damage, smoking, climate, health issues and etc.

I understand that to achieve optimum results, I may need several treatments and use home care products as
prescribe by my therapist.

I agree to refrain from solariums/sun beds while I am undergoing treatment, and during the 30 days following the
end of treatment.

I understand that extended direct sun exposure is prohibited while am undergoing   treatment and the daily use
of sunscreen protection with a minimum of SPF 30+ is mandatory.

I further agree to follow all the pre and post skin treatment/resurfacing instructions as instructed by my therapist.
 I agree to the  treatment  advised  to me by my therapist: (Select that apply )

☐Peeling / MDA
☐Cosmelan / Dermamelan
☐Mesotherapy / Biorevitalisation
☐Injection Lipolysis
☐Botox / Fillers
☐PRP / Growth Factor
☐Medical Facials / Combination with Medical Devices ( Machines )
☐Others  ______________________________

Important: Product overuse, scrubbing, picking skin and sunburn can cause temporary dryness, irritation and
temporary dark spots. Do not use sauna, get chemical hair services or skin peels, wax, use depilatory or be
exposed to prolonged direct sun for at least 14days.

I declare that I have read the entire above Informed Consent and was adequately explained the risks of this therapy,
contraindications, guidelines and benefits from this treatment, and I hereby consent to the treatment to be performed
to me. Considering that I have been informed that certain medical conditions and medications are contraindicated
thus, I have provided a full and truthful medical history and a truthful and accurate account of my medications to this
clinic.

I agree that if I should have any questions or concerns regarding my treatment/results I will notify immediately so that
timely follow-up and intervention can be provided.

Having been apprised of all the above, I have signed this Consent Form and authorize the subject treatment.

Patient Full Name & Signature: __________________________ Date & Time:

___________________

Therapist Name & Signature: ____________________________ Date & Time:

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