Name * First Name Last Name Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Aesthetician Name DECLARATION: • I have been thoroughly informed about the nature and known effects of the requested cosmetic procedure described below. • I understand this consent is personal and cannot be delegated, except if underage or under guardianship. • After a comprehensive discussion, I agree upon the choice of application and the type of cosmetic procedure. • My above named aesthetician has provided me with detailed information and guidelines about precautions and recommendations before and after the treatment to promote proper healing and avoid complications. • I understand the importance of following these precautions and recommendations to ensure the success of the procedure. PRE-APPLICATION CONDITIONS AND THERAPEUTIC ALTERNATIVES: I am aware of the need to avoid sun exposure and tanning with UVA lamps post-treatment. BENEFITS OF EVOLUTION PEEL: • Improves the skin condition of the face and neck. COSMETIC BENEFITS: • Firmer skin appearance • Refreshed skin feel • Skin feels tighter • Improved skin tones • Minimized pores • Smoother wrinkles • Visibly younger appearance • Reduced appearance of age spots MEDICAL HISTORY: * Diseases, conditions or concerns, allergies, or previous aesthetic procedures. POST-TREATMENT CARE: • Avoid extreme temperatures for 2-3 days. • Protect skin from sun and UVA-UVB rays for at least two months. Use sunblock to prevent post-inflammatory hyperpigmentation. • Avoid skin irritation for at least one month. Any treatments on exposed areas should be approved by the specialist. POSSIBLE BUT UNCOMMON COMPLICATIONS: • Cold exposure skin reaction with possible crust formation • Hypo or hyperpigmentation • Some patients may experience limited or no response to treatment. ACKNOWLEDGEMENTS: • Results are temporary and help maintain skin health. • Combination of peelings with other therapies is common for efficient biorevitalization. • Techniques and equipment used are considered best from a cosmetic-scientific viewpoint. • I am not pregnant. • I acknowledge that outcomes vary based on techniques, substances used, and individual responses. • I understand cosmetic medicine isn't exact science, and no guarantees can be given. • In case of disputes, arbitration will be preferred over judicial action. • I permit any necessary actions not specified in this document if unforeseen situations arise during the treatment. • I allow pre-treatment photos taken by the above named aesthetician for scientific documentation purposes only. • I authorize the above named aesthetician to perform the described procedure. 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 & 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! TenSkin Rx Consent Form for Evolution Peel
