Consent For Skinmedica Peels

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CONSENT FOR SKINMEDICA® PEELS

CONSENT FOR SKINMEDICA® PEELS*

PURPOSE: The SklnMedlca Peels range from very superficial to superficial, designed to Improve the texture and appearance of your skin.

PATIENTS WHO SHOULD NOT BE TREATED:

  • Patients with active cold sores or warts, skin with open wounds, sunbum, excessively sensitive skin, dermatitis or Inflammatory rosacea In. the area to be treated. Inform the esthetician If you have any history of herpes slmplex
  • Patients with a history of allergies (especially allergies to salicylates like aspirin), rashes, or other skin reactions, or those who may be sensitive to any of the components in this treatment
  • Patients who have taken Accutane® within the past year
  • Patients who are pregnant or breastfeedlng (lactating)
  • Patients who have received chemotherapy or radiation therapy
  • Patients with vitiligo
  • Patients with a history of an autoimmune disease (such as rheumatold arthritis, psoriasis, lupus, multiple sclerosis etc.) or any condlilon that may weaken their immune system

Note: Pallents who have had medical cosmetic facial treatments or procedures (e.g. laser therapy, surgical procedures, cosmetic filler, mlcrodermabrasion, etc) should wait until skin sensitivity completely resolves before recelvlng a SkinMedlca Peel.

ONE WEEK BEFORE YOUR SKINMEDICA PEEL AVOID THESE PRODUCTS AND/OR PROCEDURES*:

  • Electrolysis
  • Waxing
  • Depilatory Creams
  • Laser Hair Removal
  • Patients who have had BOTOX® tions should wate unfil full effect of their treatment is seen before receiving a SklnMedlca Peel

THREE DAYS BEFORE YOUR SKINMEDICA_PEEL AVOID THESE PRODUCTS AND/OR PROCEDURES*:

  • Retln-A®, Renova®, Dlfferin®, Tazorac®
  • Any products containing retinal, alpha-hydroxy acid (AHA) or beta-hydroxy acid (BHA), or benzoyl peroxide
  • Any exfoliating products that may be drying or irritating

*Note: The use of these producls/treatmsnts prior to your peel may fncrease skin sensitivity and cause a stronger reaction.

ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR SKINMEDICA PEEL:

It Is common and expected that your skin well be red, dry, possibly itchy and/or cremated. It is also possible that other adverse experiences (side effects) may occur. Although rare, the following atoms experiences have been reported by patients after having a SkinMed!ca Peel: skin breakout or acne, rash, swelling, and burning. Call the office immediately if you have any unexpected problems after the procedure.

VARIATIONS IN AMOUNT OF PEELING FOR VISUALIZE PUREJEWElS PEEL ONLY:

The degree of peeling may vary from mild mangostin peeling and sheets dependlng on the Individual's skin type and skin conditions at the time of the· peel. Reasons why some patients experience Ile-creased visible peeling;

  • Receiving Vitalize Peel/Rejuvenize Peel for the first time
  • Severe sun damase (Increased visible peeling should develop with subsequent peels)
  • Having peels regularly With a short interval behtween peels
  • Frequent use of Retin-A, alpha-hydroxy acids (AHA) or other peeling agents prior to the peel treatment

Regardless of the degree of peeling, the skin is still sloughing off at an accelerated rate, which will result in the Improvement of skin tone and texture, and diminishment of fines lines and plgmentatlon.

PLEASE READ AND INITIAL THE FOLLOWING:

By my signature below, I acknowledge that I have read this Consent form and uncderstand it. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. I have been adequately lnformed of the risks and benefits of this treatment and wish to proceed with this SklnMedlca Peel.

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Please make a copy of completed and signed consent force one copy in patient's file, and give one copy to patient to take home.