OxyRefresh 4-in-1 Super Facial Mega Treatment Consent Form

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Email *

What is your name? *

Prior to receiving this treatment, I have been candid in revealing any condition that may have a bearing on this procedure, such as: Pregnancy • History of skin cancer or pre-malignant moles • Excessive fresh skin tan (within the last few days) • Any active conditions in the treatment area, such as: sores, eczema, rash, fragile skin, swollen, burnt or injured skin, active acne, rosacea, dermatitis, psoriasis, or active Herpes Simplex • Vascular disorders such as: telangiectasia, varicose veins, thrombosis, phlebitis in the applied area • Severe concurrent disease such as: un-controlled diabetes, nervous diseases, cardiac disorder and cancer • Any aesthetic, ablative, surgical, invasive procedure performed recently on the applied area such as plastic or cosmetic surgery, skin resurfacing, deep chemical peels, deep dermabrasion, injected chemical or bio-material substances or fillers, and Botox • Recent use of products such as Accutane or RetinA • Known allergies to cosmetics or other products, or experienced severe allergic reactions like hive *

Yes

I understand there may be some degree of minor discomfort, i.e., scratchiness, itchiness and there are no guarantees to this procedure. *

Yes

I understand that to achieve maximum results, I will need several ongoing treatments and will need to use a daily product over a period of time. *

Yes

I understand that the possibility of irritation and redness exists and that I should notify my skin care professional when irritation persists. *

Yes

I will follow the home care regimen specifically designed for me without changing or adding any products without consulting with my Ageless Perfection Skin Care Studio. *

Yes

I have read the Contraindications and Precautions and understand the contents. *

Yes

I agree to all of the above to have this treatment performed on me and will follow all prescribed directions regarding post peel care should I receive a enzyme or chemical peel. *

Yes

Please type your name *

Please enter the date *

YYYY

Please enter the time *

Time

A copy of your responses will be emailed to the address you provided.

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