JM Studio
Daniela Ortega Bravo · Folio: JM-2026-0122 · 02 dic 1969
Servicios: Peel químico, Microdermoabrasión
Página 18 · Chemical Peel Consent Form
| I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and desire to receive the chemical peel procedure. | ☐ |
| I have been informed of the nature, risks, and possible complications and consequences of a chemical peel. I understand the chemical peel procedure may have known or unknown complications including but not limited to: infection, scarring, inconsistent color, and allergic reaction. | ☐ |
| I give permission to "JM STUDIO & SPA LLC / Joselin Ortega" to perform the chemical peel treatment on me. | ☐ |
| I request the chemical peel procedure and accept the permanence of the procedure as well as the possible complications and consequences of said procedure. | ☐ |
| Choose one: I consent _____ (initial) or waive _____ (initial) the patch test. | ☐ |
| I understand I must discontinue all oral and topical medications used at least 14 days prior and 14 days post procedure and should consult my physician before discontinuing use for the chemical peel procedure. | ☐ |
| I have received pre- and post care instructions and I will strictly adhere to such instructions. I understand that my failure to properly follow pre and post care instructions may compromise my procedure. | ☐ |
| I understand this procedure may be uncomfortable or slightly painful while being performed. | ☐ |
| Signature | |
| Date |
Página 15 · Microdermabrasion Consent
| I understand that "Joselin Ortega / JM STUDIO & SPA LLC" will perform a microdermabrasion treatment on my face, neck, decollete, or other area as determined between myself and my esthetician. | ☐ |
| The nature of this service and the potential risks involved have been explained to me, and I accept this treatment as suitable. | ☐ |
| I acknowledge and confirm that I have NOT had any tanning, waxing, dermaplaning, laser hair removal, prescription topical products, acid-based oral or topical products, or any other exfoliating products that may be drying or irritating on the area to be treated. | ☐ |
| I understand that I should not tan, wax, exfoliate, or seek a cosmetic treatment for at least 72 hours after receiving this treatment. | ☐ |
| I understand that I must wear spf 30+ with broad spectrum coverage to protect my skin during sun exposure but agree to limit sun exposure for 72 hours post treatment. | ☐ |
| I understand I must avoid excessive sweating and strenuous activities for at least 24 hours. | ☐ |
| I acknowledge and accept that I may experience some of the following side effects: redness, tenderness, swelling, irritation, dryness, tingling, peeling, and skin color changes. | ☐ |
| Signature | |
| Date |
Daniela Ortega Bravo · Firma
Jimena Morales · Ficha técnica de la profesional
JM Studio · Documento generado electrónicamente