Intimate_Peel_Consent_Form

Date

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you ever had an intimate area chemical peel before?

Do you have any history of hyperpigmentation, hypopigmentation, or keloid scarring? If yes, please explain

Are you currently using any topical products on the treatment area? (e.g., Retinoids, hydroquinone, exfoliants) (Yes / No - If yes, please list

Have you recently shaved, waxed, or used hair removal treatments in the area to be treated?

Are you currently pregnant, breastfeeding, or trying to become pregnant? (Yes / No)

Do you have any active infections, open wounds, cold sores, or rashes in the area to be treated? (Yes / No)

Are you currently taking any medications that affect your skin's sensitivity (e.g., Accutane, antibiotics)? (Yes / No - If yes, please list

Have you undergone any laser treatments, microneedling, waxing, or other professional treatments in the treatment area recently? (Yes / No - If yes, when?)

Do you understand that multiple sessions (typically 3-6) may be required for optimal results, depending on your skin concerns? (Yes / No)

Do you acknowledge that aftercare instructions must be followed carefully, including avoiding heat, sweating, and using sunscreen daily on the area if exposed? (Yes / No)

Do you understand there is a possibility of minor peeling, dryness, or irritation following treatment? (Yes / No)

Do you consent to the Intimate Peel procedure and understand the potential risks and benefits? (Yes / No)

Frequently Asked Questions – BioRePeelCl3 Rose

When can I do laser treatments?

If you’ve recently had a laser treatment, you should wait before starting BioRePeelCl3 Rose. If you’ve completed a series of BioRePeelCl3 Rose treatments, it’s recommended to wait a few weeks before undergoing any laser treatments.

Can I shave the treatment area?

Yes, you can shave the area before your BioRePeelCl3 Rose treatment.

If you prefer, you can also shave 48 hours after your BioRePeelCl3 Rose session.

No waxing for 7 days before and 7 days after the peel.

How often can I get a BioRePeelCl3 Rose treatment?

BioRePeelCl3 Rose works best in a series of 4 to 6 treatments, spaced 7–14 days apart for optimal results.

Home Care After BioRePeelCl3 Rose

Avoid heat and sweating for 24–48 hours after your treatment. (This includes hot showers, saunas, hot yoga, and gym workouts.)

Do not use retinoids or other topical active ingredients for 7 days before and 7 days after your treatment.

Keep the area hydrated along with a broad-spectrum SPF daily.

Client Acknowledgment: I acknowledge that I have answered all questions truthfully and understand the nature of the Intimate Peel procedure, including the potential risks, benefits, and necessary aftercare instructions.

Client Signature