Client Information and Consent for Laser Carbon Peel Treatments DESCRIPTION OF LASER CARBON PEEL & CARBON FACIAL PROCEDURES CARBON PEEL & CARBON FACIAL
A special Carbon Paste will be applied to areas of your face excluding an area around your eyes and a
margin around your mouth. The Carbon Paste is allowed to dry for approximately 10 – 15 minutes and
during this time will be absorbed by the superficial dead skin cells of your face but will not penetrate to
deeper living cells. A laser with a very short pulse is used to interact with the paste which causes the
Carbon to vaporize along with the dead skin cells. The resulting skin will appear fresher, and the skin's
pore size will reduce. Often blackheads/whiteheads are removed by the treatment. A series of
treatments will induce the deeper layers of the skin to produce new collagen that reduces the
appearance of fine lines.
If the optional 2 stage Carbon Facial treatment has been chosen a second pass of the laser over areas
that have fine lines will be carried out immediately following the removal of the Carbon - this enhances
the effects of the laser on the collagen fibers.
Each impact on the skin from the laser will cause a slight tingling sensation – there is no pain associated
with this Carbon Peel treatment.
There is a risk that the laser will have an adverse reaction on the skin in the treated area if your Skin
Type is too dark or if you have red spots or pigmented blemishes on your skin at the time of
treatment. Precautions will be taken to minimize this risk – your Skin Type will be assessed and any
blemishes that may cause problems noted.
You should be aware that any excess hair growing on the face will need to be shaved although the
normal fine downy hair on many women’s faces will not pose a problem. Male clients will need to have
a close shave before the treatment.
Your skin type, medical history and medication will be checked during your Consultation to make sure
you are suitable for treatment. Test patches will also be carried out during your initial visit to ensure no
adverse skin reaction will occur. Your first full treatment cannot be carried out until these test patches
have been reviewed by your Practitioner – most clients are able to commence treatment 24 – 48 hrs
after the test patch whilst those with slightly darker skin will need to wait for 10 -14 days before the
full treatment can begin. Photographs of your treatment will be made to document progress. It is a
condition of consent that you allow these test patches and photographs to be carried out.
CLIENT CONSENT FOR TREATMENT
My signature below constitutes my acknowledgment that I,
am a competent,
consenting adult of at least 18 years of age and further, that I:
• Have read and understood the information provided in this form;
• Have had my procedure adequately explained to me by my practitioner;
•Have had the opportunity to ask questions, and all of my questions have been answered to
my satisfaction;
• Have received all of the information I require concerning my procedure;
• Understand all post treatment recommendations and agree to adhere to them
• Freely assume any risks of complications or injury from known or unknown causes
associated with, relating to, or otherwise arising out of this procedure;
•Have the right to consent to or refuse any proposed procedure at any time prior to its
performance
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.