Chemical Peel Consent Form

Prior to receiving treatment, I have disclosed any condition that may impact this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores / fever blisters, or use of topical and/or oral prescription medications such as: tretinoin, Retin-A®, isotretinoin, Accutane®, Differin®, Tazorac®, EpiDuo® or Ziana®.*

I understand there may be some degree of discomfort such as tingling, pin-pricking sensation, heat or tightness.*

I understand there are no guarantees as to the results of this treatment, due to many variables such as: age, condition of skin, sun damage, smoking, climate, etc.*

I understand this treatment is a cosmetic treatment and no medical claims are expressed or implied.*

I understand that I may need several treatments to achieve optimal results.*

I understand that although complications are rare, they may occur and that prompt treatment is necessary. In the event of complications, I will immediately contact the clinician who performed the treatment.*

I agree to refrain from tanning in a tanning bed or outdoors while I am undergoing treatment, and during the 14 days prior to and following the end of the treatment.*

 understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum SPF of 30 is mandatory*

I have not had any other chemical peel or any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location.*