PATIENT PROFILE

Name *

First Name Last Name

Date *

Date

Home Number *

Please enter a valid phone number.

Work Number *

Please enter a valid phone number.

Cell Number *

Please enter a valid phone number.

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

initial* The treatment was explained to me in detail.

initial* The benefits of what I can realistically expect to see from my Clinical Peel have been fully explained to me.

Treatment (select one): *

Ormedic Lift Signature Lift Lightening Lift Wrinkle Lift Acne Lift Beta Lift Image Perfection Lift TCA Orange Peel

Skin Condition: *

	No	Yes
Superficial Wrinkles, Fine Lines
Deep Wrinkles, Fine Lines
Acne or Acne Prone
Deep Hyperpigmentation (sun or brown spots)
Severe Photoaging
Rosacea
Dehydration
Acne Scars
Unbalanced

PRECAUTIONS

The treatment you will receive is a clinical treatment designed to exfoliate or remove the outer layers of the skin.

Your participation in your skincare treatments will determine the outcome. It is important that you strictly adhere to your home care products that your aesthetician has recommended.

No guarantee is expressed or implied as to the precise results, peeling times or discomfort.

During the treatment, you may experience some temporary stinging or warm flushing. This will fade within a few minutes. During the next few hours, you may experience some tightening of the skin, which may last for several days.

For most patients, flaking begins within 48 hours. It is impossible to pre-determine how much peeling will occur. The shedding process usually subsides within 5-7 days.

Depending on the clinical peel performed and your skin quality, the following reactions may occur in some patients:

Prolonged redness, irritation, and flakiness
Dryness and sensitivity
Severe allergic reactions in rare instances

Please read carefully and initial each statement:

initial here* I am not pregnant.**

initial here* I have not used glycolic acid for 24 hours.

initial here* I have not taken Accutane in the past year.

initial here* I agree not to pick, peel, or scratch the skin during the healing phase.

initial here* I agree there may be crusting and shedding of the skin.

initial here* A prior patch test has been given to me to rule out any allergic tendencies.

initial here* I agree that I currently do not use Hydrocortisone.

initial here* I do not have active cold sores.

initial here* I have not received radiation treatments.

initial here* I agree it is mandatory to use the Image post peel kit.

initial here* I agree to avoid direct sun exposure for 2 weeks.

initial here* I agree to notify the Doctor/Aesthetician of any concerns.

initial here* I agree to apply Image Prevention+.

initial here* I agree not to wax for 7 days pre/post treatments.

initial here* I agree to follow up with scheduled appointments.

initial here* I agree not to use Retin-A products 7 days pre/post treatments.

initial here* I am under the supervision of a physician and have discussed the treatment plan with my physician.

**Exceptions: Ormedic Lift and Signature Lift are safe for pregnant women.

I hereby give my consent and authorization voluntarily and release Limitless Medspa from any claims, implied or stated that I have or may have in the future with this treatment, regardless of the result. I am stating that the treatment and precautions above have been explained to me in detail and that I fully understand.

Patient Name *

First Name Last Name

Patient Signature *

Clear

Date *

Date

Staff Witness Signature

Clear

Date

INFORMED CONSENT FOR IMAGE TREATMENTS