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Moxi® Informed Consent 

I hereby authorize Restorative Skincare to perform laser Moxi treatment on me


Purpose of Treatment

MOXI laser treatment is a non-ablative fractional laser procedure used to improve overall skin tone and texture.

It may help address:

  • Sun damage and pigmentation
  • Uneven skin tone
  • Early signs of aging
  • Mild texture irregularities
  • Preventative skin maintenance

The treatment works by delivering controlled laser energy to the skin, stimulating collagen production and promoting skin renewal.

2. Expected Results

Results vary between individuals. Multiple treatments may be recommended to achieve optimal outcomes.

I understand that:

  • Improvement may occur gradually over several weeks.
  • Multiple sessions may be required.
  • No guarantees have been made regarding the outcome of this procedure.


3. Treatment Procedure

During the procedure:

  • The treatment area will be cleansed.
  • A topical numbing cream may be applied.
  • The laser device will be passed over the treatment area.
  • Treatment typically takes 15–30 minutes depending on the area treated.

Following treatment, I may experience redness similar to a sunburn and a sandpaper-like texture to the skin for several days.


4. Potential Risks and Side Effects

While the procedure is generally safe, potential side effects may include:

  • Redness
  • Swelling
  • Warmth or tenderness
  • Temporary darkening of pigmented spots
  • Dryness or rough skin texture
  • Mild peeling or flaking
  • Itching

Less common risks may include:

  • Infection
  • Prolonged redness or swelling
  • Hyperpigmentation or hypopigmentation
  • Blistering or scarring

I understand that these risks are uncommon but possible.


5. Contraindications

I understand that I should not undergo treatment if I have:

  • Active skin infections in the treatment area
  • Open wounds or severe irritation
  • Certain photosensitive medical conditions
  • Recent use of certain medications that increase photosensitivity
  • Recent excessive sun exposure or tanning

I agree to disclose all medical conditions, medications, and skincare products I am using.


6. Pre- and Post-Treatment Care

I understand that proper care before and after treatment is important for safety and results.

I agree to:

  • Avoid sun exposure and tanning before and after treatment.
  • Use sunscreen daily (SPF 30 or higher).
  • Follow all post-treatment instructions provided by the clinic.
  • Avoid harsh skincare products until the skin has healed.

Failure to follow aftercare instructions may increase the risk of complications.

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 MOXI LASER TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM. 

Date: May 30, 2026

First Participant's Name
First 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 Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
Last Name*
Participant's Date of Birth*
Date of Birth
Photograpy
Photographic documentation may 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*
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 Photograpy
Photographic documentation may 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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