Chemical Peel Wavier

Name*

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Contradictions:

1.Herpes Simplex( Cold Sores/ Fever Blisters)

2. Extensive Sun or tanning 3 days prior or 3 days post treatment

3. Accutane in the last 6 months

4. Topical retinol products(perscription strength) in the past 3 days

5. Waxing of area to be treated in the past 7 days

6. Any other chemical peel within the last 14 days

7. Allergy to asprin

Initial that you understand the contradictions*

Risks and complications:

I am aware of the following:

1. Mild to moderate discomfort or pain

2. Slight redness or swelling

3. Sun sensitivity

4. Skin Sensitivity

5. Pigment changes

6. Scarring

7. Allergic reaction

8. Bacterial infection

Initial that you understand the Risks and complications*

I understand, read and completed the questionnaire truthfully. I understand that withholding ANY information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand that this waiver replaces any verbal or written disclosures. The treatments I receive here are voluntary, and I release Ashley Lynn Esthetics and/or esthetician from any liability, and I assure full responsibility thereof. I hereby grant irrevocable consent to and authorize the use of any reproduction by Ashley Lynn Esthetics, all photographs which are taken of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video or live internet stream shall become and remain the property of Ashley Lynn Esthetics, solely and completely. I understand and release Ashley Spina from any liability if I should fall or hurt myself in any way on her property located at 641 Union Rd. I understand that Ashley Spina is not responsible for lost, stolen or damaged items including my vehicle that is parked on the property.*

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