Chemical Peel BioRePeelCl3 Consent Form To the CLIENT: You have the right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment. 1. I voluntarily request that GLO AESTHETICS LLC perform the BioRePeelCl3 TCA chemical peel procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin. 2. Peels, despite their high levels of efficacy and safety, are not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment. 3. It is important to use sunscreen of SPF 50 or greater when exposed to the sun. 4. I understand complications can include white heads, cold sores, infection, scarring, numbness, and permanent discoloration. 5. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a few treatments over time with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received. 6. I have been explained the Pre- and Post-Treatment Instructions. I agree to follow these instructions carefully. 7. I CERTIFY that I am not on any retinal, Retin-A or actives that have been explained to me could cause minor complications during the pel process, burning sensation, peeling. I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. The nature and purpose of the treatment have been explained to me. I have read and understand this agree. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment. NOTE: All prices are subject to change without prior notice. Name * First Name Last Name Phone * (###) ### #### Email * Signature * Date * MM DD YYYY Thank you!
