Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
The treatment was explained to me in detail.
The benefits of what I can realistically expect to see from my Clinical Peel have been fully explained to me.
PEEL the signature facelift
Inital all concerns that apply
SUPERFICIAL WRINKLES, FINE LINES
DEEP WRINKLES, FINE LINES
ACNE OR ACNE PRONE
DEEP HYPERPIGMENTATION (SUN OR BROWN SPOTS)
The treatment you will receive is a clinical treatment designed to exfoliate or remove the outer layers of the skin.
Your participations in your skincare treatments will determine the outcome. It is important that you strictly adhere to your home care products that your aesthetician has recommended.
No guarantee is expressed or implied as to the precise results, peeling times or discomfort.
During the treatment you may expericence some temporary stinging or warm flushing. This will fade within a few minutes. During the next few hours, you may experience some tightening of the skin, which may last for several days.
For most patients, flaking begins within 48 hours. It is impossible to pre-determine how muhc peeling will occur. The shedding process usually subsides within 5-7 days.
Depending on the clinical peel performed and your skin quality, the following reactions may occur in some patients: 1) prolonged redness, irritation, flakiness 2) Dryness and sensitivity 3) Severe allergic reactions in rare instances
I AM NOT PREGNANT.**
** The signature lift is safe for pregnant women
AM NOT ALLERGIC TO ASPIRIN.
I HAVE NOT USED GLYCOLIC ACID FOR 24 HRS.
I HAVE NOT USED RETINOL PRODUCTS FOR 72 HRS.
HAVE NOT TAKEN ACCUTANE IN THE PAST YEAR.
I AGREE NOT TO PICK, PEEL, OR SCRATCH THE SKIN DURING HEALING PHASE
AGREE THERE MAY BE CRUSTING AND SHEDDING OF SKIN.
A PRIOR PATCH TEST HAS BEEN GIVEN TO ME TO RULE OUT ANY ALLERGIC TENDENCIES.
AGREE THAT I CURRENTLY DO NOT USE HYDROCORTISONE.
I DO NOT HAVE ACTIVE COLD SORES.
HAVE NOT RECEIVED RADIATION TREATMENTS OR CHEMOTHERAPY.
I AGREE IT is MANDATORY TO USE IMAGE POST PEEL KIT.
I AGREE TO AVOID DIRECT SUN EXPOSURE FOR 2 WEEKS
AGREE TO NOTIFY DR/AESTHETICIAN OF ANY CONCERNS.
I AGREE TO APPLY IMAGE PREVENTION+ DURING HEALING PHASE.
I AGREE NOT TO WAX FOR 7 DAYS PRE/POST TREATMENTS.
AGREE TO FOLLOW UP WITH SCHEDULED APPOINTMENT.
I AGREE NOT TO USE RETIN A PRODUCTS 7 DAYS PRE/POST TREATMENTS.
I AM UNDER THE SUPERVISION OF A PHYSICIAN AND HAVE DISCUSSED THE TREATMENT PLAN WITH MY PHYSICIAN.
I hereby give my consent and authorization voluntary and release SKINVIGO LLC and JULIE SCHWETLICK from any claims, implied or stated that, I have or may have in the future, regardless of result. I am stating that the treatment and precautions above have been expelained to me in detail and that I fully understand.
THE DAY OF YOUR PEEL
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