Revival Shot Client consentΔThe Belinic Revival Shot is a high-performance skincare treatment that utilizes micro-spicules to penetrate deep into the skin, stimulating cellular regeneration and supporting skin renewal. For a safe and effective treatment, please read the following information carefully and sign below.1.CLIENT INFORMATIONFull Name Date of Birth (YYYY/MM/DD Phone Number 2.PRE-TREATMENT SKIN ASSESSMENT Please check the appropriate box for your safety.• Are you currently taking oral acne medications (e.g., Isotretinoin/Accutane)? Yes NoHave you received any laser treatments, chemical peels, or excessive exfoliation within the past 2 weeks? Yes NoAre you currently using Retinol, Retin-A, Tretinoin, AHA, BHA, or other exfoliating products within the past 5 days? Yes NoDo you have a history of keloid scarring, severe atopic dermatitis, or active skin infections? Yes NoDo you have any skin allergies or severe autoimmune conditions? Yes NoAre you currently pregnant or breastfeeding? Yes No3.NORMAL POST-TREATMENT REACTIONS (PLEASE READ CAREFULLY)During the skin regeneration process, the following reactions may occur. These are normal responses and are not considered side effects. Irritation / Tingling Sensation As the micro-spicules remain in the skin for approximately 24—72 hours, you may experience a mild prickling or tingling sensation, especially when washing your face or applying skincare products. Redness and Warmth Your skin may appear red and feel warm or flushed for 1—2 days following the treatment. Mild Swelling and Itching Temporary swelling or itching may occur as the skin regeneration process is activated. Please avoid scratching the treated area and increase hydration as needed. Flaking and Temporary Breakouts Dead skin cells may begin to flake off within 3—5 days. Congestion and underlying impurities may temporarily surface during the renewal process.4.POST-TREATMENT HOMECARE INSTRUCTIONS Washing Your Face To ensure proper absorption and fixation of the micro-spicules, do not wash your face (including water-only rinsing) for 24 hours after treatment. Beginning the following day, gently cleanse with lukewarm water and a mild cleanser. Moisturizing & Regeneration Your skin may feel temporarily dry as the micro-channels remain open. Apply the recommended regeneration cream and moisturizer frequently to maximize treatment results and support skin recovery. Sun Protection Your skin will be highly sensitive following treatment. Avoid direct sun exposure as much as possible during the first 24 hours. After 24 hours, daily application of SPF 50+ sunscreen is mandatory. Reapply as needed when outdoors and follow all post-treatment sun protection recommendations. Activities to Avoid for 1 Week Avoid activities that increase body heat, including: Alcohol consumption Saunas Steam rooms Intense exercise Do not forcibly remove flaking skin or use physical scrubs.5. CLIENT CONSENT & CONFIRMATION5.1. I have received a full explanation and understand the nature of the Belinic Revival Shot treatment and its normal post-treatment reactions, including tingling, redness, itching, flaking, and temporary breakouts. Yes No5.2. I agree not to wash my face or apply makeup for approximately 24 hours after treatment and will strictly follow all homecare instructions provided. Yes No5.3. I understand that SPF 50+ sunscreen must be applied daily after the first 24 hours following treatment and that failure to follow post-treatment instructions may affect my results. Yes No5.4. I agree that HEAL SKIN LAB is not liable for any complications resulting from failure to follow the recommended aftercare instructions, including but not limited to picking the skin, excessive sun exposure, alcohol consumption, sauna use, or improper homecare. Yes No5.5. I understand that individual results may vary depending on skin condition, lifestyle, and adherence to homecare recommendations. No specific results have been guaranteed. Yes NoI have read and fully understood all of the information above and voluntarily consent to proceed with the treatment.Date Client Signature NB MedSpa Signature Submit Form
