I, (blank), have read the below information and initialed each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my esthetician. I give permission to my esthetician, (blank), to perform the chemical treatment we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I understand my esthetician will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate account of any over-the-counter or prescription medications that I use regularly, and I am not presently using (nor have I within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to esthetician. I am not ingesting or using topically any other over-the-counter or prescription medication/agent that has not been disclosed to my esthetician. I am not presently pregnant or lactating and I am over the age of eighteen (18). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.