Alumier MD Patient Consent Form

FULL DISCLOSURE

Prior to receiving treatment, I have completed and signed the Patient Profile given to me by my physician/ skincare professional. I have been truthful in disclosing information that may have bearing on this procedure without limitation:

I have not taken Roaccutane in the last six months

I am not pregnant/IVF/breastfeeding

I have declared all known allergies including Aspirin.

I do not have an autoimmune illness

I have not had a cold sore in the last 7 days

I am not currently receiving cancer treatment

I have disclosed all prescription and nonprescription products that I am using

CONDITIONS OF TREATMENT

I agree to follow all post-procedure protocols recommended by my physician/skincare professional

I agree to use the recommended sun protection product (SPF 30 or higher) on the treated area for a minimum of 14 days post treatment. I understand AlumierMD recommends using a sunscreen of SPF 40 or higher.

I agree to refrain from the following activities for 7 days post treatment and accept full responsibility for any adverse event that occurs as a result of my participation in these activities: • Waxing, threading, and use of all other depilatories • Neurotoxin injections (e.g., Botox, Dysport) • Use of retinoids • Use of mechanical exfoliants • Use of topical AHA/BHA and all other exfoliant topical skincare products • Use of sunless tanning products • Acne topical treatments

I agree to refrain from the following activities for 14 days post treatment and accept full responsibility for any adverse event that occurs as a result of my participation in these activities: • Sun or tanning bed exposure • Microdermabrasion • Laser hair removal • Dermal filler injections

I understand and accept that the following may occur post treatment: • Likely: Temporary sensation of heat and itchiness immediately following treatment • Possible: Contact dermatitis, inflammation(redness), oedema (swelling), skin irritation (itchiness) • Unlikely: Hyperpigmentation/ hypo-pigmentation: I agree to follow the recommended post-procedure instructions to minimise the chance of this occurring.

LIMITATIONS OF CHEMICAL
PEELING TREATMENT

I understand there are no guarantees as to the results of this treatment due to many variables including age, skin condition, sun damage, smoking habits and climate.

I understand that this treatment is cosmetic and that no medical claims are expressed or implied by AlumierMD or by the skincare professional.

I understand that to achieve maximum results, I may require several treatments.

POSSIBLE ADVERSE EVENTS

I understand that although adverse events are rare, they do occur, and prompt treatment is necessary.

In the event of any adverse event outlined below I will immediately discontinue use of all professional treatments and contact the physician/skincare professional who performed my treatment.

CONSENT TO TREATMENT

I hereby certify that all the information that I have provided has been accurate and truthful.

I acknowledge reading all the information contained herein regarding the possible adverse events associated with the treatment, that such adverse events have been properly explained and that I consent to such treatment with full knowledge thereof.

I acknowledge that I have been able to ask any questions regarding my concerns around this treatment.

I hereby agree to treatment in alignment with all considerations outlined in this consent form.

SIGNED PATIENT

Date

SIGNED PRACTITIONER

Date

AFTER YOUR TREATMENT

AlumierMD skin treatments result in minimal downtime but create dramatic and visible results. However, treatments may cause the following for two to 24 hours (these are normal, expected outcomes and are not reason for concern):

• Redness / Tightness / Itchiness / Sensitivity /
Slight swelling

Specific treatments may cause the following for three to five days. These are normal, expected outcomes and are not reason for concern:

• Temporary dryness / Skin peeling / flaking

Following specific treatment, you will be asked to avoid getting the skin wet for eight hours.

Following treatment, you will be asked to avoid makeup, self tan products, direct sun exposure, ice or ice water on the treated area and excessive heat for the rest of the day.

Following treatment, you will be asked to avoid hot tubs, steam rooms, saunas, excessively hot showers, swimming and aerobic exercise for two days.

Following treatment, you will be asked to avoid AHA and BHA skincare for three to five days.

Following treatment, you will be asked to avoid electrolysis, waxing, threading or any other form of hair removal for seven days.

Following treatment, you will be asked to avoid tanning booths, facial scrubs or mechanical forms of exfoliation, retinoic acid, laser hair removal, photofacials, chemical peels or microdermabrasion for 14 days.

You will be given a Post Peel Kit, which contains SensiCalm cleanser, Hydrating Recovery Balm and Sheer Hydration Broad-Spectrum Sunscreen SPF 40 Untinted. If you have any questions regarding your treatment, don’t hesitate to contact your AlumierMD professional who will be happy to speak with you further.

You have just received an AlumierMD Skin Treatment. Results from your chemical peel treatment can be affected by a number of factors. To maximise on the potential of your treatment and reduce the risk of complications, please follow the postpeel instructions outlined in this form.

WHAT TO EXPECT

AlumierMD skin treatments result in minimal to no downtime but create dramatic and visible results. Treatments may cause the following for 2 – 24 hours (these are normal, expected outcomes and are not reason for concern):

• Redness / Tightness / Itchiness / Sensitivity /
Slight swelling

Specific treatments may cause the following for three to five days (these are normal, expected outcomes and are not reason for concern):

• Temporary dryness / Skin peeling / Flaking

The treated area may or may not actually peel as each treatment is individual.
It may take two or more treatments to target the deeper layers of skin to loosen and 'peel'.
The degree of peeling does not necessarily reflect the efficacy of the procedure.
Refrain from removing peeling skin by any means including picking, peeling and exfoliating as it could result in hyperpigmentation or scarring.

CARING FOR YOUR SKIN
AFTER TREATMENT

Avoid the makeup / self tanning products / direct sun exposure, ice or ice water on the treated area and excessive heat for the rest of the day.

Avoid hot tubs, steam rooms, saunas, excessively hot showers, swimming and aerobic exercise for two days.

Avoid AHA and BHA skincare for three to five days.

Avoid electrolysis, waxing, threading or any other form of hair removal for seven days.

Avoid tanning booths, facial scrubs or mechanical forms of exfoliation, retinoic acid, laser hair removal, photofacials, chemical peels or microdermabrasion for 14 days.

In case of emergency such as allergic reaction, please contact your physician and proceed to the nearest emergency room.

YOUR POST-PEEL KIT

This post-treatment kit has been created to care for your skin following a chemical peel or professional treatment. Follow the post-peel regimen and use only the three AlumierMD products in this kit for five to seven days:

SENSICALM CLEANSER (15 mL / 0.5 Fl. oz)

A smooth hydrating cleanser, that delicately removes impurities and excess oil while calming skin. Yucca root extract is a gentle natural cleanser; niacinamide, ceramides, vitamin E and sunflower seed oil moisturise, leaving skin smooth, soft and intensely hydrated. Aloe soothes skin and calms redness.
Instructions: Massage into skin and rinse thoroughly.

RECOVERY BALM (15 mL / 0.5 Fl. oz)

Specifically formulated for post-procedure recovery and packed with soothing and antioxidant ingredients, this moisturiser relieves redness and calms skin.
Hinokitiol and sea whip relieve redness, aloe, honey and boswellia soothe and copper peptide rehabilitates the look of skin.
Instructions: Gently massage into clean skin with
fingertips. Apply during the day as needed.

SHEER HYDRATION BROAD SPECTRUM
SPF 40 SUNSCREEN (15 mL / 0.5 Fl. oz)

A silky and sheer physical sunscreen that provides powerful protection against harmful UVA and UVB rays. It uses a combination of zinc oxide and titanium dioxide, while moisturising with vitamin E. This formula is also packed with free-radical quenching antioxidants, including resveratrol, grapeseed extract and glutathione, to protect skin from UV damage.
Instructions: Apply liberally to treated areas after cleansing and applying Recovery Balm. Reapply throughout the day.

I agree to follow all post peel instructions outlined in this document and accept full responsibility for any adverse event that occurs as a result of me failing to do so.

A.M. PROTOCOL

STEP 1: SensiCalm Cleanser
STEP 2: Recovery Balm
STEP 3: Sheer Hydration Broad Spectrum
Sunscreen SPF 40

P.M. PROTOCOL

STEP 1: SensiCalm Cleanser
STEP 2: Recovery Balm

Discontinue use if any products cause burning on the skin and contact your skincare provider.

If you have any questions or concerns, please contact The Skin & Lifestyle Edit.

SIGNED PATIENT

Date

Signed Practitioner

Date

Patient Consent

POST-TREATMENT CARE

POST-PEEL INSTRUCTIONS