BIOREPEELCL3 BLUE/GOLD CHEMICAL PEELΔClient Name Phone Date Of Birth Email To the Client: You have the right to be informed about the nature and purpose of the proposed treatment, its expected benefits, possible risks and alternatives, so that you may decide whether to proceed. This disclosure is intended to help you provide or withhold informed consent.1. Voluntary Request and Purpose I voluntarily request that NB MedSpa perform the BioRePeelCl3 BLUE/GOLD TCA chemical peel treatment. I understand that this cosmetic procedure is intended to exfoliate superficial layers of the skin and improve skin texture, tone, vitality and overall appearance.2. Expected Reactions I understand that chemical peels are generally well tolerated but are not free of side effects. Redness (erythema) and swelling (edema) may occur and may last from several hours to seven days or longer. Irritation, itching, mild burning, tenderness or discomfort similar to sunburn may occur during treatment or within 48 hours afterward. Dryness, tightness, flaking or peeling may also occur.3. Sun Protection and Aftercare I agree to use broad-spectrum sunscreen with SPF 50 or higher when exposed to daylight and to follow all pre-treatment, treatment-day and post-treatment instructions provided by NB MedSpa. I understand that sun exposure may increase the risk of irritation and pigmentation changes.4. Possible Risks and Complications I understand that possible complications may include breakouts or whiteheads, cold-sore reactivation, infection, prolonged redness, swelling, numbness, scarring, delayed healing and temporary or permanent changes in skin colour, including hyperpigmentation or hypopigmentation. Although uncommon, allergic or unexpected reactions may occur.5. Results and Additional Treatments No guarantee, warranty or assurance has been made regarding the results of this treatment. I understand that clinical results vary from person to person, improvement is usually gradual, and additional or maintenance treatments may be required to achieve or maintain the desired res6. Safety Instructions, Payment and Refunds I agree to follow all safety precautions and practitioner instructions before, during and after treatment. I understand that treatments already received are non-refundable and that I am personally responsible for payment for all services rendered. I understand that prices are subject to change without prior notice.7. Pre- and Post-Treatment Instructions The pre- and post-treatment instructions have been explained or provided to me. I agree to follow them carefully and to contact NB MedSpa promptly if I experience an unusual, severe or prolonged reaction.8. Retinoids and Active Skincare Products I confirm that I have disclosed my use of retinoids, Retin-A/tretinoin, retinol, retinal, exfoliating acids, benzoyl peroxide, hydroquinone and other active skincare products. I confirm that I have followed the practitioner’s instructions regarding when to discontinue them before treatment.9. Acknowledgement, Alternatives and Right to Refuse The nature and purpose of the treatment, its risks, expected benefits and reasonable alternatives have been explained to me. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand that I may refuse or withdraw consent before the procedure begins. I voluntarily consent to treatment under the terms of this agreement.TREATMENT DETAILSTreatment Date: Treatment Area(s): Product/Peel Used: Batch/Lot No.: Application Time/Layers: Skin Response: Practitioner Notes: Aftercare Provided: Yes No1 I declare that all information provided by me in this form is accurate and complete. Any omission, concealment, or incorrect information is solely my responsibility, and I release Zia Cosmetic Clinic and its staff from any liability arising from such inaccuracies.Submit Form
