VI Peel Consent Form

VI Peel Consent Form
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The VI Peel contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.
Contraindications:
- Patients who are pregnant or who are breast feeding
- Patients who have an aspirin, hydroquinone or phenol allergy
- Patients who have used oral isotretinoin (Accutane) within the past 6 months
- Patients who have active cold sores, warts, open wounds or history of herpes simple
- Patients who are undergoing chemotherapy and or radiation therapy within 6 months
- Patients with a history of an autoimmune (i.e. Lupus) or liver disease/disorder as well as any condition that may weaken their immune system
Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during and a week after the procedure.I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.I understand that maintenance of VI Peel treatments are necessary to maintain results as well as the recommended VI Dermskin care regimen and SPF 50+.I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel.I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub steam room and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)I understand that I must protect my skin with VI Derm SPF 50+and avoid sun exposure during the 7 day exfoliation process.I understand that this is an elective cosmetic procedure.I understand that no other chemical peels, facial machine brushes or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so.
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VI Peel Consent Form

Contraindications: