TenSkin Rx Consent Form for Carbon Peel Name * First Name Last Name Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Aesthetician Name * First Name Last Name DECLARATION: I have been adequately informed about the nature and known effects of the cosmetic procedure detailed below. I understand that this consent is personal to me and cannot be delegated to relatives unless I am underage or under guardianship. I have decided on this cosmetic procedure after receiving a comprehensive explanation about the pre-application conditions and therapeutic alternatives. The practitioner named above, has provided me with all necessary information regarding precautions and post-treatment care to facilitate proper healing and prevent complications. I am aware that not following precautions may adversely affect the treatment outcome. I am committed to following all post-treatment instructions. I understand the need to avoid sun exposure and tanning with UVA lamps after treatment. CARBON PEEL DETAILS: Recommended For: • Improving wrinkles • Enhancing skin elasticity Benefits: • Refreshes the skin • Aids acne-prone skin • Smoothens wrinkles • Firms the skin • Reduces age spots MEDICAL HISTORY: * Diseases, conditions or concerns, allergies, or previous aesthetic procedures. POST-TREATMENT CARE: •. Avoid extreme temperatures for 2-3 days after the treatment. •. Shield your skin from sun and UVA-UVB rays for a minimum of two months. Use sunblock to prevent post-inflammatory hyperpigmentation. •. Refrain from irritating the skin for at least one month. Seek approval from the specialist before undergoing any treatments on exposed skin areas. POSSIBLE BUT UNCOMMON COMPLICATIONS: • Cold exposure skin reaction leading to crust formation •. Hypo or hyperpigmentation •. Minimal or no noticeable results from the treatment ACKNOWLEDGMENTS: • I acknowledge that results are temporary and help maintain skin health. • I declare that I am not pregnant. • I understand that the outcome can vary based on the techniques, substances used, and individual body responses. • I acknowledge that the practice of cosmetic medicine is not an exact science, and no guarantee can be provided regarding the expected outcome. • In case of any disputes, I agree to arbitration rather than judicial action. • I permit the aesthetician to undertake any necessary actions not specified in this document, should unforeseen situations arise during the treatment. • I give permission to the above-named aesthetician to take pre-treatment photos exclusively for scientific documentation. •. I authorize the above-named aesthetician to perform the above-described procedure. CONSENT: By signing below, I confirm understanding and agreement with all the above points. I've had the opportunity to ask questions and have received satisfactory answers. Date MM DD YYYY ACKNOWLEDGEMENT & AGREEMENT: * By checking this box, I acknowledge that I have read, understood, and agreed to all terms and conditions outlined in this document. I voluntarily consent to proceed with the outlined procedures or treatments. I AGREE AESTHETICIAN'S ACKNOWLEDGEMENT AND CONFIRMATION: * By checking this box, I, the aesthetician, confirm that I have thoroughly discussed all relevant information with the patient/client, and I am prepared to proceed with the outlined procedures or treatments in accordance with the terms and conditions of this document. Aesthetician Agrees Thank you!
