The Perfect Derma Peel Consent Form

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.
Contraindications:
- Patients who are pregnant or breastfeeding.
- Patients with an allergy to any peel ingredients 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 who have had waxing, electrolysis or chemcial exfoliants within a week.
- Patients who are undergoing chemotherapy and or radiation therapy.
- Patients with a history of autoimmune disease or any condition that may weaken the immune system.
Prior to receiving treatment, I have informed my esthetician about any medications or health conditions that may contraindicate this treatment.I understand tat there might be some discomfort such as stinging, redness,burning,itchiness or tightness during and a week after the treatment. I understand that it is important not to pull, pick at or remove peeling skin forcibly.I understand that there is no specific guarantee as to the final results of the peel, and that I may require more than one treatment for optional results.I understand that while complications are extremely rare, they may occur. in the event of a reaction or complication, I agree to immediately contact my esthetician for follow up care.Occasionally hyper pigmentation of hypo pigmentation may develop which can persist for weeks or months after the treatment.I understand that post peel care includes use of mineral perfection SPF 30 or above and avoid sun exposure during the exfoliation process.I understand that extended sun exposure, including use of tanning beds is prohibited both before and after the perfect derma peel treatment. Avoid sweating excessively or use of steam/sauna for 3 days post peel.I understand that this elective treatment procedure is non refundable.I understand that no other chemical peels or medical device treatments are to be performed on my skin until my esthetician releases me to do so.I give consent for either Erlinda or Katelyn to preform the Perfect Derma Peel on my skin I understand the above information entirely and if I have any questions I will ask my esthetician before treatment.
Patient signature

Clear
Date

MonthDayYear
Date
Should be Empty: