AI WELLNESS CENTER OF EXCELLENCE
TOPICAL & INFUSION SKIN BOOSTERS CONSENT FORM
INFORMED CONSENT & AUTHORIZATION

This consent form confirms that I have been informed about the use of topical and infusion-based skin boosters, including but not limited to Rejuran®, exosomes, Klardie Ruby®, Klardie Dia®, peptides, collagen-based formulations, growth-factor–containing products, and similar bioactive cosmetic or aesthetic preparations.

I understand the purpose, potential benefits, limitations, risks, contraindications, and alternatives, allowing me to make an informed and voluntary decision regarding treatment at AI Wellness Center of Excellence.

DESCRIPTION OF SKIN BOOSTERS

I understand that skin boosters are topical or infusion-assisted products designed to support skin quality, hydration, texture, elasticity, and overall skin appearance.

I understand that these products may be applied topically, in conjunction with aesthetic devices such as microneedling, laser, radiofrequency, ultrasound, or photobiomodulation, as post-procedure treatments, or as infusion-assisted or transdermal delivery treatments.

I understand that skin boosters may contain one or more bioactive components, including but not limited to polynucleotides, exosomes or extracellular vesicle–based products, peptides and amino acids, collagen-supportive compounds, growth factors, antioxidants, vitamins, minerals, cofactors, and hydration-supporting agents.

I understand that some products may be used off-label or outside FDA-approved indications, within accepted aesthetic and wellness practice standards.

INTENDED BENEFITS (NO GUARANTEES)

I understand that potential benefits may include improved skin hydration, enhanced skin texture and smoothness, improved skin tone and radiance, support of collagen and elastin activity, improvement in the appearance of fine lines, support of skin barrier repair, and enhanced post-procedure recovery.

I understand that results vary by individual and that no specific aesthetic outcome can be guaranteed.

LIMITATIONS & EXPECTATIONS

I understand that skin boosters are not medical treatments, are not intended to diagnose, treat, or cure disease, and do not replace medical or surgical skin treatments.

I understand that optimal results often require multiple applications or combination therapies, and that outcomes depend on individual biology, skin condition, lifestyle factors, and adherence to care recommendations.

ALTERNATIVES

I understand that alternatives include no treatment, medical or prescription skincare, injectable treatments, device-based aesthetic procedures, or surgical or medical dermatologic treatments. These alternatives have been discussed with my provider.

RISKS & POSSIBLE ADVERSE EFFECTS

I understand that skin booster treatments are generally well tolerated; however, possible side effects may include local skin reactions such as redness, warmth, mild swelling, sensitivity or tenderness, itching or tingling, dryness or flaking, and temporary breakouts or irritation.

I understand that post-procedure reactions may include increased sensitivity following device-assisted delivery, temporary inflammation, delayed redness, or irritation.

I understand that allergic or hypersensitivity reactions may occur, including rash, hives, contact dermatitis, or rare allergic responses.

I understand that additional considerations include uneven results, minimal or no visible improvement, or delayed response.

I understand that unknown or unforeseen side effects may occur, particularly with newer bioactive or regenerative-inspired products.

I agree to notify AI Wellness Center of Excellence immediately if I experience persistent irritation, signs of infection, swelling, pain, or any concerning symptoms.

CONTRAINDICATIONS & PRECAUTIONS

I understand that skin booster treatments may not be appropriate if I have known allergies to product ingredients, active skin infections, rashes, or open wounds in the treatment area, autoimmune or inflammatory skin conditions without provider clearance, a history of severe allergic reactions, a compromised immune system, or if I am pregnant or breastfeeding.

I understand that it is my responsibility to disclose all medical conditions, allergies, medications, supplements, and prior reactions before treatment.

POST-TREATMENT RESPONSIBILITIES

I understand that adherence to post-care instructions is important to minimize side effects and optimize results.

I agree to notify the clinic promptly of any adverse reactions and allow AI Wellness Center of Excellence to participate in management if issues arise.

FINANCIAL & NO-REFUND POLICY

I understand that payment is for professional services and products provided and not for a guaranteed result, and that there are no refunds for patient-determined unsatisfactory outcomes.

PROVIDER AUTHORIZATION

I authorize Dr. Gideon Kwok, D.O., and/or trained and qualified associates to apply or administer topical or infusion-assisted skin boosters as part of my aesthetic treatment plan.

I acknowledge that I have had the opportunity to ask questions regarding provider qualifications and am satisfied.

VOLUNTARY CONSENT & FINAL ACKNOWLEDGMENT

I certify that I have read, understood, and agree to the contents of this consent form. This document supersedes any prior verbal or written disclosures, and I freely consent to topical and infusion-based skin booster treatments.