Facial/Chemical Peel Informed Consent

I understand that this is a cosmetic treatment and that no claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol. I understand that there are no guarantees as to the result of this treatment, due to the many variables such as age, conditions of the skin, sun damage, smoking, and climate. | may or may not experience actual "peeling" with this procedure, as each case is individual. I understand that there is some degree of discomfort, i.e.: stinging, "pin-pricking" sensation, hotness, or tightness. I understand that although complications are rare, they may sometimes occur, and prompt treatment is necessary. In the event of any complications, I will immediately contact Glennda Rios at (626)610-5736 Iagree to refrain from tanning or excessive sun exposure while | am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sunblock protection with a minimum SPF 30 is mandatory. I have revealed any medical conditions that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medications such as Accutane, hormone, replacement therapy, or use of Retin-A. Contraindicated medications should be discontinued 72 hours before the treatment except Accutane, which must be discontinued six months prior. I have not had a peel treatment of any kind within 14 days of my treatment. I understand I cannot have another treatment until recommended by a licensed professional. I understand my responsibility for properly fulfilling the appropriate aftercare instructions explained by Glennda Rios PHOTOGRAPHS: I give permission for photographs to be used by Skin Karma for educational and promotional purposes. Complete patient confidentiality will be maintained at all times.(please initial

Before receiving treatment, I have been candid in revealing any condition that may affect this procedure as outlined. I will also inform Glennda Rios of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety.