CONSENT TO RESURFACING PEEL TREATMENT

The instructions provided in this informed consent should be followed by all patients receiving a Resurfacing Peel Treatment. You will be asked to sign this form acknowledging that you have read and understood all of the information presented.

RESURFACING PEEL TREATMENT PURPOSE: The Resurfacing Peel Treatment is a superficial peel designed to improve the texture and appearance of your skin.

PATIENTS WHO SHOULD NOT BE TREATED: Patients who have any of the following conditions or underwent or have been prescribed any of the following therapies or medications:

• Active cold sores or warts
• Skin with open wounds, sunburn, excessively sensitive skin
• Dry eye conditions, such as keratoconjunctivitis sicca, inflammation of the cornea and conjunctiva of the eyes
• Dermatitis or inflammatory rosacea in the area to be treated
• Autoimmune disease
• A history of herpes simplex
• Keloids or raised scars
• A history of allergies, rashes or other skin reactions
• Cancer
• Human chorionic gonadotropin or human chorionic gonadotrophin (hCG) or any hormone therapy
• Topical Fluorouracil, also known as "5-FU" and sold under such brand names as Efudex, Carac and Fluoroplex
• Chemotherapy, radiation therapy or taken Accutane within the last year
• Pregnant or breastfeeding (lactating) women 

Patients who are one week pre-menstrual or on their menses may experience more sensitivity, redness or flaking and this should be taken into consideration when scheduling your Resurfacing Peel Treatment.

ONE WEEK BEFORE YOUR RESURFACING PEEL TREATMENT: Avoid these products and/or procedures:

• Electrolysis
• Waxing
• Sunless tanning, spray tanning or UV free tanning
• Depilatory Creams
• Laser Hair Removal
• Patients who have medical cosmetic facial treatments or procedures (e.g. laser therapy, surgical procedures, cosmetic filler, microdermabrasion, etc.) should wait until skin sensitivity completely resolves.
• Patients who have had BOTOX injections should wait until all bruising subsides
• Retin-A® (tretinoin), Renova® (tretinoin), Differin® (adapalene), Tazorac® (tazarotene), Avage® (tazarotene).
• Any products containing Retinol, AHA or BHA, or Benzoyl Peroxide.
• Any exfoliating products or procedures that may be drying or irritating  

Note: the use of these products/treatments prior to your peel may increase skin sensitivity and cause stronger reactions.

AFTER YOUR RESURFACING PEEL TREATMENT: It is crucial to the health of your skin and success of your peel that these guidelines be followed:

1. It is imperative that you use a sunscreen with an SPF of at least 30 and avoid direct sunlight for at least 1 week.

2. Best results will be obtained with regular daily use of such sunscreen.

3. Patients with hypersensitivity to the sun should take extra precautions to guard against exposure immediately following the procedure as their skin may be more sensitive.

4. Your skin may be more red than usual. Please avoid strenuous exercise during this time.

5. Approximately 48 hours after the treatment, your skin will start to peel. This peeling will generally last 2 to 5 days. DO NOT PICK OR PULL THE SKIN.

6.When washing your face, do not scrub, do not use a wash cloth. Use the Sensi Cleanse provided.

7. Apply the Riche Hydrate Plus as directed and as needed to relieve dryness, tightness and itching.

8. Use only the products in your Resurfacing Peel Treatment kit. Do not use any other skincare products until directed to do SO by your skincare professional.

9. Wait until the peeling is complete before having ANY OTHER FACIAL PROCEDURES, INCLUDING: 

• Facials
• Microdermabrasion
• Laser treatments
• Laser hair removal
• BOTOX injections
• Injectable fillers

 

ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR PEEL: It is common and expected that your skin will be red and possibly itchy and/or irritated. It is also possible that other adverse experiences (side effects) may occur. Although rare, the following adverse experiences have been reported by patients after having a Resurfacing Peel Treatment: skin breakouts or acne, rash, dark spots (hyperpigmentation), light spots (hypopigmentation), swelling, burning and skin wrinkling (skin atrophy).

 

Call the office immediately if you have any unexpected problems after the procedure.

 

 

LACK OF EFFECT: Although most people experience peeling of their facial skin, not every patient notices that their skin peels after a Resurfacing Peel Treatment. Lack of peeling is NOT an indication that the peel was

unsuccessful. If you do not notice actual peeling, please know that you are still receiving all the benefits of the Resurfacing Peel Treatment, such as: improvement of skin tone, texture and a decrease in the appearance of fine lines and wrinkles.

There are a number of reasons why a patient may not have peeling or may experience minimum peeling. The reasons may include:

• Having peels regularly with a short interval between peels
• Frequent use of Retin-A, AHA, or other peeling agents prior to the Resurfacing Peel Treatment
• Severe sun damage

Proper skin evaluation by your skin care professional prior to your peel is important and will help predict the outcome of your peel.

 

Please read and initial the following:

By my signature below, I acknowledge that I have read this Resurfacing Peel Treatment informed consent form and understand it. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the Resurfacing Peel Treatment.

For Office Staff: Please make a copy of the completed and signed consent form. Place the original in the patient's file and give one copy to the patient to take home.