VI Aesthetics For the Life of Your Skin

First Name*

Last Name*

Email*

Patient email on file

Date*

Date

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 breastfeeding
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*

Initial

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.*

Initial

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.*

Initial

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.*

Initial

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.*

Initial

I understand that maintenance of VI Peel treatments are necessary to maintain results as well as the recommended VI Derm skin care regimen and SPF 50+.*

Initial

I understand that this is an elective cosmetic procedure.*

Initial

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.)*

Initial

I understand that I must protect my skin with VI Derm SPF 50+and avoid sun exposure during the 7 day exfoliation process.*

Initial

I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®*

Initial

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.*

Initial

that overheating may cause me to develop blisters or cause hyperpigmentation to worsen

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

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Patient Signature*

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Provider Name*

First NameLast Name

Provider Signature*

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Vi Peel Consent