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Peel Consent Form
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
D.O.B
(Required)
DD slash MM slash YYYY
Medical
Medical
(Required)
Select exactly
4
choices.
I currently have no cold sores and if I have the Herpes Virus I will prep on an antiviral.
I am not currently pregnant or breastfeeding.
I have no allergies that will contraindicate me to having the treatment. E.g. Salicylic acid
I do not have open lesions, eczema or inflamed skin on the area to be treated
Nature of treatment
Medical
(Required)
Select exactly
6
choices.
I understand that there are no guaranteed results from this treatment. Many variables exist such as age, sun damage, ongoing sun exposure, smoking, excessive alcohol intake, climate, diet and water intake, skin thickness and sensitivity.
I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin which may or may not result in skin peeling or flaking as each case is individual.
I understand that it may take several treatments to obtain the desired results.
I understand the goals of the treatment as well as the limitations and possible complications outlined in this form
I will immediately contact the Doctor, Nurse or Skin Specialist performing the treatment if any complications arise
l accept sole responsibility for any medical care that may become necessary as a result of complications such as hypopigmentation, infection and / or scarring
Home care compliance
Medical
(Required)
Select exactly
3
choices.
I will not scratch, pick, pull at or abrade the treated skin.
I understand that direct sun exposure and use of a tanning booth is prohibited during this treatment time, and that a minimum SPF 25 physical sun protection (no fragrance) must be applied daily.
I understand that to achieve maximum results and to avoid complications the recommended home care routine must be followed. I understand that if I alter the routine or use products not recommended by the skin care professional, the results could be altered or inhibitive.
Photographic release
Photographs are taken of your skin prior to starting a series of treatments, and again at the completion of your treatments for the purpose of documenting progress being made.
Photographic consent
(Required)
I hereby authorise photographs to be taken of me before, during, and after my treatment
I hereby do not authorise photographs to be taken of me before, during, and after my treatment
Confirmation
Consent
(Required)
I agree
My Skin Specialist has provided the information and has answered all my questions concerning this procedure. I clearly understand all information outlined in this form. I agree to these terms and I wish to proceed with this procedure as indicated.
Name
(Required)
First
Last
Date
(Required)
DD slash MM slash YYYY
Signature
(Required)
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