REQUIRED *

At TenSkin Rx we take your safety and well-being very seriously, therefore, we ask that you take the time to read the following carefully and fill in accordingly: I, the undersigned understand that the TenSkin Rx Marine Peel treatment I am about to receive is elective and that complications, although rare, are possible. Possible complications may include but are not limited to: blistering, crusting, itching, pain, bruising, skin whitening, burns, infection, scabbing, scarring, swelling, and temporary redness, discolouration in the area being treated. Your TenSkin Rx skin specialist will properly explain the aftercare instructions that support this peel process. TenSkin Rx reserves the right to refuse this service to anyone. TenSkin Rx requires that patients be at least 16 years of age or accompanied by a parent or guardian to undergo this procedure. The TenSkin Rx Marine Peel treatment has been fully explained to me and my questions and concerns have been addressed. I understand that no specific results are guaranteed. By my electronic signature below, I acknowledge that I have read and fully understand the INFORMATION ABOVE AND HEREBY CONSENT AND AGREE TO THE TREATMENT WITH ITS ASSOCIATED RISKS.

Please check all that apply:

I verify that I am not pregnant.

I verify that I do not have a history of skin cancer on the area to be treated.

I verify that to my knowledge I do not have any localized infections in the area being treated.

I verify that I have read and agree to the above terms and conditions.

Name

First Name

Last Name

Date

YYYY

MARINE PEEL CONSENT FORM