BioRePeel Consent Form

Name

First NameLast Name

Email

example@example.com

Address

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DOB

Date

List all skincare products you are currently using

What concern(s) are you looking to target with BioRePeel?

I voluntarily request that Studio 22 Aesthetics 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.
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. It is important to use sunscreen of SPF 30 or greater when exposed to the sun. I understand complications can include white heads, cold sores, infection, scarring, numbness and permanent discoloration.
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.

5-7 days before the treatment I have/will avoid laser hair removal, waxing, chemical hair removal creams, electrolysis, topical retinoids, tretinoin, other topical acids and any exfoliants.

Post Peel I will avoid non-mineral based make-up products, exfoliants, retinol, laser hair rempval, waxing, sunbeds, swimming and saunas for 7 days.
I have been explained the pre and post treatment instructions. I agree to follow
these instructions carefully.

I CERTIFY that I am not on any retinol, Retin-A or actives. These products can cause minor complications during the peel process such as burning sensation or peeling.

I CERTIFY that I do not have active bacterial, viral, fungal or herpetic infecton, open wounds, pre-existing inflammatory dermatosis (psoriasis, atopoc dermatitis, etc.), pregnant or nursing, history of drugs with photo-sensitizing potanetial, use of accutane within the last 6-8 months, underwent any kind of surgery and not fully recovered or an apirin allergy.

I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. I understand Studio 22 Aesthetics does not issue refunds for services or opened product.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. 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.

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