The Perfect Derma Peel Consent Form
The Perfect Derma Peel is a medium depth, medical grade chemical peel suitable for all skin types. The peel contains Trichlorocacetic Acid (TCA), Retinoic Acid, Kojic Acid, Salicylic Acid, Phenol, Glutathione and Vitamin C.
Patients who are pregnant or breast feeding Patients with an allergy to any peel ingredient listed above, or to aspirin Patients who have used Accutane within the past 4 months Patients who have open wounds, sunburn, infected skin, cold sores or lesions. Patients with a history of cold sores (herpes simplex) may be given an antiviral 3 days prior to the peel Patients who have recently had treatments such as waxing, electrolysis or chemical exfoliants Patients who are undergoing chemotherapy and/or radiation therapy Patients with a history of an autoimmune disease or any condition that may weaken the immune system
Please read and initial the following:
Prior to receiving treatment, | have informed my medical professional about any medications or health conditions that may contraindicate this treatment.