Chemical Peel Consent Form

The Chemical Peel contains a synergistic blend of powerful ingredients suitable for all skin types. The Chemical peel will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation ( Including Melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.


Contraindications:


- Patients who are pregnant or who breastfeeding


- Patients who have and aspirin, hydroquinone or phenol allergy


- Patients who have used oral isotretinoin (Accutane) within the past 6 months


- Patients who have active cold sores, warts, open wounds or history of herpes simple


- Patients who are undergoing chemotherapy and or radiation therapy within 6 months


- Patients with a history of an autoimmune ( i.e Lupus) or liver disease/disorder as well as any condition that may have weaken their immune system

I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during and a week after the procedure.

I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.

I understand although complications are very rare, sometimes they occur. In the event of any complications, I will immediately contact the Physician/ Clinician who performed the treatment.

I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.

I understand that maintenance of the chemical peel treatments are necessary to maintain results as well as the recommended chemical peel skin care regimen and SPF 50+

I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the chemical peel

I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub, steam room and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)

I understand that I must protect my skin with the recommended post peel product/ kit(s) and avoid sun exposure during the 7 day exfoliation process.

I understand that this is an elective cosmetic procedure.

I understand that no other chemical peels, facial machine brushes or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so.

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I understand that this treatment is non-refundable. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.