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CoolPeel® Informed Consent 

I hereby authorize Restorative Skincare to perform laser C02 treatment on me. I understand that this procedure works to ablate the tissue on the treatment area. I understand that I may require several treatments to obtain a significant, long-term results. I understand I may experience redness, dryness, sloughing of the tissue, mild to moderate sunburn sensation and/or bleeding post treatment. I understand all the potential side effects, as discussed with me prior to treatment. I understand that genetics, hormones, medication and skin color may interfere with the ability to perform an effective treatment. 

The procedure may result in the following adverse experiences or risks:

  • DISCOMFORT/PAIN – Some discomfort and/or pain may be experienced during treatment, but is unlikely.
  • REDNESS/SWELLING/BRUISING – Redness (erythema) or swelling (edema) of the treated area is common and may occur. There also may be some bruising.
  • HYPOPIGMENTATION / HYPERPIGMENTATION: (Changes in skin Color): – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
  • WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated area(s), but is unlikely.
  • SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase risk of side effects and adverse events.
  • INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call us.
  • SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post- treatment instructions provided by your healthcare staff.
  • EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage. 

I acknowledge the following points have been discussed with me:

  • Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
  • Alternative treatments and my options
  • Reasonably anticipated health consequences if the procedure is not performed
  • Possible complications/risks involved with the proposed procedure and subsequent healing period
  • For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment.

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR COOLPEEL LASER TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM. 

Date: February 22, 2026

First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
I hereby authorize _______________________________ to perform laser C02 treatment on me.

I acknowledge the following points have been discussed with me:

Photographic documentation will be taken. I hereby do___do not___authorize the use of my photographs for teaching purposes.*
I hereby do authorize
do not authorize
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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