Lavender Med Spa & Salon

3520 Breckinridge Blvd # 110, Duluth GA 30096
Email: lavendermedspa@gmail.com Tel: (678) 829-7721

Carbon Facial/hollywood Peels Consent Form

Client's Name:

Form's Name:

Client's DOB:

Client's Phone#:

1. Procedure Description

This non-invasive laser treatment uses a carbon solution and laser energy to deeply cleanse, exfoliate, and rejuvenate the skin, improving tone, texture, and overall appearance.

2. Benefits

Improves acne, oil control, enlarged pores, pigmentation, and enhances skin brightness and smoothness.

3. Risks & Side Effects

Possible temporary redness, warmth, sensitivity, dryness, or rare pigmentation changes. In rare cases, burns or scarring may occur.

4. Pre & Post Care

Pre: Avoid sun, tanning, and active skincare 3–5 days prior.
Post: Avoid heat, gym, sun for 24–48 hrs. Use SPF daily and gentle skincare.

5. Medical Questionnaire

Recent sun exposure/tanning (2 weeks)?
Yes No

Used self-tanner (3 weeks)?
Yes No

Taking photosensitizing meds?
Yes No

Pregnant or suspect pregnancy?
Yes No

History of cold sores/herpes?
Yes No

History of skin cancer?
Yes No

Taken Accutane in last 12 months?
Yes No

Any unusual skin changes?
Yes No

6. Acknowledgment

I understand the procedure, risks, and that results vary. All my questions have been answered.

Informed Consent

I consent to treatment and release the spa from liability. NO REFUNDS ON ANY TREATMENTS.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THAT ABOVE INFORMATION AND THEREBY CONSENT AND AGREE TO THE TREATMENT WITH ITS ASSOCIATED RISK. I HEREBY CONSENT TO RECEIVE A CHEMICAL PEEL.

Signature:

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Date: