CHEMICAL EXFOLIANT INFORMED CONSENT

GENERAL lNFORMATION: Chemical skin peels and other skin treatments have been performed for many years to treat a variety of skin disorders. This treatment is used to treat sun damage, wrinkling, acne scars, aging skin, and uneven pigmentation. There are many different techniques and regimens for the application of chemical-peeling and skin treatment medications.

ALTERNATIVE TREATMENTS: Alternative forms of management include not treating the skin with chemical-peeling agents or other medications. Improvement of skin lesions and skin wrinkles may be accomplished by other treatments such as dermabrasion, laser treatment, or surgery to tighten loose skin. Risks and potential complications are associated with alternative forms of treatment.

RISKS OF CHEMICAL SKIN PEEL/ SKIN TREATMENTS: Every procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual's choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you sbould discuss each of them with your practitioner to make sure you understand all possible consequences of chemical exfoliation and other forms of skin treatment. Possible side effects include: infection, scarring, color change, Accutane (may impair the ability of skin to heal), allergic reactions, lack of permanent results, heart problems, skin discoloration, swelling, skin sensitivity, damaged skin, pain, and unknown risks (may be discovered).

SUN EXPOSURE /TANNING / ADDITIONAL ADVISORIES: The effects of the sun are damaging to the skin. Exposing the treated areas to sun may result in increased scarring, color changes, and poor healing. Patients who tan, should inform their practitioner and either delay treatment, or avoid tanning until indicated that it is safe to resume. The damaging effect of sun exposure occurs even with the use sun block or clothing coverage. Clients who smoke, exposed to second-hand smoke, intake Nicotine Products (Patch, Gum, and Nasal Spray) are at a greater risk for complications, delayed healing and additional scarring.

Client Acknowledgement

I confirm that I fully understand what to expect. My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one treatment may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun, environmental damage, pigmentation levels, or acne condition. *

Initials

I understand my practitioner will take every precaution to minimize or eliminate negative reactions. I do understand that risks associated the treatment. I have given an accurate account of my skin condition, skin treatments/products, medications/supplements/antibiotics (topical oral), medical history, medical procedures, life events and or any other information which could impact the results of this treatment(s). *

Initials

I am not presently pregnant lactating, over the age of eighteen (18), have not had any recent radioactive or chemotherapy treatments, wind burned or have broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with positive outcome of this treatment. *

Initials

I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree to inform the skin immediately if I have concerns or am overly uncomfortable during treatment or after I return home. *

Initials

I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for following home regimens minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, extreme weather conditions I agree to use a moisturizer specifically recommended by my therapist and adhering to any additional post *

Initials

I acknowledge that I have been informed of the possible negative reactions and the expected sequence of the healing process (dryness, redness, and peeling of the skin). I am aware that I am not to rub or peel off the skin layers that will loosen and peel automatically as a of the treatment. *

Initials

Green Peels Treatment Clients: I am aware that a follow up treatment with active ingredients will be out by practitioner As the skin after the peeling treatment is particularly permeable, this treatment contains especially valuable ingredients, which will enhance and strengthen the peeling treatment. Until the follow up treatment with active ingredients you are not allowed to wash the treated and not apply makeup (with the exception of eye makeup and lipstick). *

Initials

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