Green Peel – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical care or taking any medications? *

Yes

No

Check if you use any of the following : *

Retinol or Retin-A

Accutane (within 6 months)

AHA/BHA acids

Steroids or immunosuppressive medications

Have you had any recent cosmetic treatments (chemical peels,laser, microneedling)? *

Yes

No

If yes, please explain shortly and provide dates: *

Treatment Goals and History

Let us know about your skin care goals and the products you are using : *

Treatment Information & Contraindications

Have you had a Green Peel Treatment before? *

Yes

No

Let us know about your experience : *

Do you have known allergie to herbs or natural plant-based ingredients? *

Yes

No

List the allergies : *

Do you currently have any sunburn, skin irritation, or rashes in the treatment area? *

Yes

No

Have you been sun exposed or tanned in the past 2 weeks? *

Yes

No

Do you have any history of post-inflammatory hyperpigmentation? *

Yes

No

Procedure Information

Microneedling involves the use of fine needles to create controlled micro-injuries in the skin to stimulate collagen and elastin production.

Topical anesthetic may be applied to reduce discomfort.

A course of treatments is typically recommended to achieve the best results.

Post-treatment redness, sensitivity, and mild swelling are common for up to 48 hours.

Client Declaration and Consent

Read and initial the statements for Green Peel Facial : *

I understand that the Green Peel is a plant-based herbal peeling treatment that promotes skin regeneration.

I understand that the procedure may cause redness, flaking, tingling, tightness, and peeling for several days.

I acknowledge that the results vary depending on individual skin condition and adherence to aftercare.

I understand that sun exposure, makeup, and active skincare products should be avoided during recovery.

I understand that Green Peel is not suitable for open wounds, active infections, or inflamed skin.

I will inform the practitioner of any unusual discomfort or adverse reactions after the treatment.

I agree to follow all pre- and post-treatment care instructions provided by Idens Laser Clinic.

I consent to photographs for clinical records. These will not be shared without my written permission.

Risks, Side Effects, and Acknowledgements

Check all boxes for Green Peel Facial : *

I confirm that the information provided is accurate and complete.

I have read and understand the nature, purpose, and potential risks of the Green Peel treatment.

All my questions have been answered to my satisfaction.

I voluntarily consent to undergo the Green Peel treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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Treatment Goals and History

Treatment Information & Contraindications

Procedure Information

Client Declaration and Consent

Risks, Side Effects, and Acknowledgements

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