To the Patient: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.
1. I voluntarily request that Medisthetics & Laser Clinic Medical Technician may perform the Peel procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin.
2.Peels, despite their high levels of efficacy and safety, are not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.
3. It is important to use sun screen of SPF 30 or greater when exposed to the sun or when around blue light devices.
4. A chemical peel can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance of hyperpigmentation.
5.Multiple treatments are required in order to obtain optimal results spaced 2-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.
2. Herpes Simplex (cold sores or fever blisters). An anti-viral medication may be necessary prior to treatment.
3. Extensive sun or tanning 3 days prior and 3 days post treatment.
4. Accutane in the past 6 months to 1 year.
5. Topical retinol products in the past 2 weeks.
6. Waxing or Laser of area to be treated in the past 7 days.
7. Any other chemical peel within 14 days of the treatment.
8. Skin must be healthy and intact.
I am aware of the following risks/complications that may occur:
1. Mild to moderate discomfort or pain
2. Slight redness or swelling
3. Sun sensitivity
4. Skin sensitivity
5. Pigment changes
7. Allergic reaction
8. Bacterial infection
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may
have a bearing on this procedure.
I consent and authorize Medisthetics & Laser Clinical Medical Technician to perform one or more chemical peels on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Medisthetics & Laser Clinical Medical Technician from all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the future as well.
I will inform the clinic of any medical changes during my treatment schedule. I will notify the clinic if I have any questions or concerns immediately by phone, email or text.