I confirm that I consent to receiving a JetPeel treatment. Iunderstand that the JetPeel system is used to treat various skin, scalp, and body conditions. I understand that JetPeel is a treatment that can be used to provide lymphatic drainage, hydradermabrasion, chemical peeling and infusion of solutions according to skin condition. JetPeel system uses a handpiece that accelerates liquids that are sprayed into the skin in a safe and effective manner. I understand that a complete cycle of 4-6 treatments, spaced a week apart, may be needed achieve optimal results. I understand that clinical results may vary depending on individual factors, including, but not limited to medical history, skin type, patient compliance with pre/post procedure instructions, and individual response to treatment. I understand that in rare cases there is a possibility of short-term effects, such as reddening, mild burning, temporary slight swelling of the skin, rash and tingling especially during the exfoliation, as well as the possibility of rare side effects such as scabs, discoloration or individual allergic reaction to ingredients of the solutions. These effects have been fully explained to me. I understand there must be at least the following window of time lapsed before a JetPeel treatment: Fillers - 4 weeks I Botulinum toxin A injections - 3 weeks Electrolysis - 1 week Microneedling - 1-3 days I certify that I have been fully informed of the nature and purpose of the procedure, expected outcome, and possible complications. I understand that no guarantee can be given as to the results obtained. I am fully aware that my condition is of cosmetic concern and the decision to proceed is based solely on my expressed desire to do so. I have informed the practitioner and staff regarding any current or past medical condition, disease, or medication taken, and any allergic reactions. I have informed the practitioner that I use systemic or topical retinoids. Iconfirm that I don't have any contraindications for JetPeel treatment such as active infections, allergic reaction to cold temperature, metastatic disease, active skin diseases in acute stage, pregnancy, breastfeeding. Iconfirm that I am over the age of 18 and am duly authorized to act on my own behalf. (Initial) I give permission to use my before and after pictures. (Initial) I do not give permission to use my pictures in any format. I need to remain anonymous (eyes blacked out I give permission to use my full face pictures (no blackout
| certify that I have been given the opportunity to ask questions and all my questions have been answered and that I have read and fully understand the content of this consent form. I accept all risks of treatment and agree to provide aftercare as directed by this facility.