We'd Like To Get To Know You! Please Complete The Following Form
Your information is confidential and is saved to your account. A copy of this form is available upon request.
Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click
here. By clicking YES below, I acknowledge this privacy notification.
I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform Bloom Health and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from Bloom Health are voluntary and I release Bloom Health, PLLC from liability and assume full responsibility thereof.
Purpose of This Consent Form
The purpose of this section is to provide written information regarding the risks, benefits, and alternatives of treatment with CoolPeel CO2 laser resurfacing. This material serves as a supplement to the discussion you have with your Bloom Health provider. It is important that you fully understand this information, so please read thoroughly. If you have any questions, please speak with your Bloom Health provider prior to submitting this consent form.
Treatment Goals and Description of Procedure
CoolPeel is a fractional CO2 laser skin resurfacing procedure that uses the DEKA SmartXide Tetra device to deliver short, high-peak power pulses that treat signs of aging, texture irregularities, fine lines, large pores, and sun damage. Unlike traditional CO2 lasers, CoolPeel delivers similar benefits with less thermal injury to the skin, resulting in minimal downtime. The treatment is non-invasive and performed in-office. Depending on your skincare goals, your treatment may be tailored with topical numbing, paired add-ons (such as exosomes or glacial cooling), or combined with other modalities.
Treatment Results
Many patients experience visible improvement after a single CoolPeel treatment, though optimal results are typically achieved in a series of 3 or more treatments spaced 4–6 weeks apart. Skin texture and clarity may continue to improve over the course of several months due to ongoing collagen remodeling. Results vary depending on age, skin condition, adherence to aftercare, and general health. While most patients are pleased with the results, no guarantees can be made regarding specific outcomes.
Aftercare Instructions
Following your CoolPeel treatment, you will be provided with written and/or verbal aftercare instructions. These include, but may not be limited to: 1) Avoid sun exposure and wear a minimum of SPF 40 sunscreen daily; 2) Mild redness, dryness, or a sandpaper-like texture may occur and resolve in 3–5 days; 3) Avoid active skincare products (retinoids, acids, scrubs) until cleared by your provider; 4) Do not pick, peel, or exfoliate the skin; 5) Keep the skin hydrated with a gentle moisturizer; 6) Contact us immediately if you suspect infection, prolonged irritation, or any adverse reaction.
Potential Risks and Complications
While CoolPeel is generally considered safe and low-risk, all procedures carry potential side effects. These may include but are not limited to: 1) Redness, dryness, peeling, irritation, swelling, or discomfort; 2) Post-inflammatory hyperpigmentation or hypopigmentation; 3) Acne breakouts or milia; 4) Reactivation of cold sores (herpes simplex virus); 5) Rare risk of infection, scarring, or burns. Adherence to aftercare is essential to minimizing risk.
Pregnancy and Contraindicated Conditions
I am not aware that I am pregnant. I am not trying to get pregnant. I am not currently breastfeeding. I have notified my Bloom Health provider of any medical conditions, medications, or recent facial treatments. I do not have any open wounds, infections, or history of keloids in the treatment area. I do not have a history of light-triggered seizures or photosensitive disorders. I am not taking any medications that increase sensitivity to light (e.g., isotretinoin, doxycycline).
Alternative Therapy
CoolPeel is an elective cosmetic procedure. Alternatives may include chemical peels, microneedling, traditional CO2 laser resurfacing, non-ablative laser treatments, plasma resurfacing, or doing nothing at all. Your provider will help determine the best course of treatment for your goals and skin type.
Payment
I understand that CoolPeel is not covered by insurance and that payment is my responsibility, due at the time of treatment.
Right to Discontinue Treatment
I understand that I have the right to discontinue treatment at any time.
Release of Liability
I hereby release and hold harmless Bloom Health, PLLC and its affiliates from any liability associated with this elective treatment. I understand that all questions and post-treatment concerns should be directed to my Bloom Health provider. I understand that my provider is licensed and trained to perform this procedure and that outcomes may vary.
Consent to Treatment
By entering my initials below, I voluntarily consent to receive CoolPeel CO2 laser resurfacing as performed by my Bloom Health provider. I acknowledge that I have read and understand the above. I am not under the influence of drugs or alcohol, and all of my questions have been answered to my satisfaction. I understand the risks and benefits of this elective procedure. This consent applies to all future CoolPeel treatments I choose to receive at Bloom Health.
