Consent to RevePeel, ReveFresh, Enlighten Rx
A: DO NOT USE THIS PEEL IF YOU:
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Are pregnant or breast-feeding
Are allergic to salicylates (i.e aspirin) hydroquinone or any ingredient in this peel
Have open wounds, sunburn, infected, irritated or extremely sensitive skin
Have active cold sores, warts, or herpes simplex
Have used Accutane within 180 days
Had a peel within the past 30 days
Have used products that contain Retinoic acids, AHA & BHA in the last 7 days. Doing so may cause strong reaction
The skin has not recovered from a recent cosmetic procedure or treatment like waxing, botox, cosmetic filler, microdermabrasion, Laser, IPL Photo Facial, etc.
Have recent history of chemotherapy or radiation therapy
Have dermatitis and inflammatory rosacea
B: Potential adverse experiences may occur after REVEPEEL & ENLIGHTEN RX MASK. It is common and expected that your skin will be possibly red, itchy, dry, irritated, and discolored for several days. Although rare, some patients may experience acne, crusting, tightness, dryness, rash, swelling or burning sensation, or minimal peeling and dark spots (hyperpigmentation). Call the office immediately if you have any serious unexpected problem after the procedure.
Please Read the following and initial below
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I do not have any conditions listed under section A above.
I understand that it is critical to follow REVEPEEL and or Enlighten Rx Post Care Instructions strictly and wash off the peeling solution on time per the instructions given by medical professionals to avoid any potential complications like post inflammatory hyperpigmentation.
I understand that the actual amounts of peeling and actual degree of skin improvement cannot be guaranteed. The peeling result varies and depends on each patient's skin condition. Several peels may be required to achieve the optimal result.
I understand that proper skin maintenance is necessary to maintain the peeling results.
I understand that this peel contains strong acids including TCA, Phenol, Salicylic Acid, Lactic Acid, Hydroquinone and Retinol. I waive any rights, present or future to request the information of exact composition or concentration.
I acknowledge that no guarantee has been made or implied as to the results of the peel procedure.
Initials
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By my signature below, I acknowledge that I have read this consent form and understand it. I had opportunities to ask questions and these questions have been answered to my satisfaction. I have been informed of the benefits and risks of this chemical peel and I am willing to proceed with the "REVEPEEL" or Enlighten. I here by authorize Gabrielle Gentile and Dr. Manolakakis to perform the REVEPEEL or Enlighten.
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