Refresh Evolution

Complete Laser & Wellness Health Care

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Chemical Peel Consent Form

  • I understand everything explained to me in my consultation including the following that may have a bearing or possible side effect on this procedure during and post treatment:
    • Accutane use, pregnancy, nursing, history of cold sores, allergies, aspirin allergy
    • Hyper/Hypopigmentation
    • Contact Dermatitis, inflammation(redness), edema(swelling), skin irritation(itchiness)
    • Temporary sensation of heat and itchiness immediately following treatment

    PEELING: I understand that I may or may not actually peel and that each treatment is individual. I understand that the degree of peeling does not correlate with the degree of improvement.

    CONDITIONS OF TREATMENT: I agree to refrain from the following activities for 14 days following my treatment:
    • Sun/tanning bed,microdermabrasion, laser hair removal, photo facials, chemical peels, laser/rf treatments, use of retinols, use of mechanical exfoliants, use of topical AHA/BHA and all other exfoliant topical skin care products

    I agree to refrain from the following activities for 7 days post:
    • Waxing, threading, all use of depilatories, neurotoxin injections, dermal filler injections, tanning products, acne topical treatments

    I agree to disclose names of any prescription/non prescription products I am using. I agree to follow post treatment protocols recommended by my skin care professional. I agree to use a professional, medical grade sun protection SPF 30+ for a min of 14 days.

    Limitations to treatment: I understand there are no guarantees as to the results of this treatment due to many variables including age, skin condition, sun damage, smoking, climate etc. I understand that this treatment is cosmetic and that no medical claims are expressed or implied. I understand that to achieve max results I may require several treatments and the suggested at home skin.

    COMPLICATIONS: I understand that although complications are rare, they do occur and prompt treatment is necessary. In the event of complication I will contact the skin care professional who performed my treatment. I hereby certify that all the information I have provided has been accurate and truthful. I agree to follow post treatment care instructions provided to me.
  • Date Format: MM slash DD slash YYYY
    Please select all that apply.
  • Date Format: MM slash DD slash YYYY
  • ELECTRONIC CONSENT: Please select your choice below. Clicking on the "agree" button below indicates that: • I have read and fully understand this agreement and all information detailed above

Launch Event

October 23rd 7-9pm

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Pitt Meadows Location

Refresh Evolution - Pitt Meadows
#105-10996 Barnston View Road.
Pitt Meadows BC V3Y 0B9
Phone: 778-806-4758

Port Moody Location

Refresh Evolution - Port Moody
86 Kyle Street
Port Moody BC V3H 1Z3
Phone: 778-806-4758

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