Chemical Peel Consent

Chemical Peel Consent
I consent and authorise my practitioner to perform a Chemical Peel on me. I understand the following points and have had the opportunity to ask any questions that may arise during my consultation.
In relation to Chemical Peels, I have been advised as follows:
1. Treatment is successful on most clients but individual results cannot be guaranteed.
2. There may be swelling and discomfort following the peel and the chemically burned area may tighten, scab, and peel within 3-5 days, temporarily leaving the skin inflamed. Redness after a chemical peel may persist for long periods of time and is still considered normal.
3. The treated skin may be sensitive from a few days to over a week. Direct sunlight to the area must be avoided for 24-48 hours and the use of SPF 30+ is mandatory, starting immediately post treatment.
4. Darker skin type clients will require additional treatments due to low intensity application.
5. Not following the program regarding timing of treatments and aftercare advice will reduce/affect efficacy of the treatment.
Even though the risk of complication is extremely low, the following can occur:
(Please read thoroughly and understand)
In relation to my initial and all subsequent treatments I advise that:*

I have completed the client consultation documentation truthfully, and my practitioner has consulted with meI understand what chemical peel treatments entail and have had all my questions answered satisfactorilyI acknowledge my expectations are realistic, and I understand that the results are not guaranteedI acknowledge that I have been informed of the possible adverse reactions and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin)I am aged 18 years or over (otherwise parent or guardian to sign)I will advise my practitioner of any changes that occur during my treatment that can increase potential risks or reduce efficacyI agree that I am willing to follow recommendations for home care. I will be responsible for following home regimens that can minimise or eliminate possible reactions, including recognising the importance of adhering to sun protectionIf i have any further questions or concerns, I will address these with my practitionerI also understand there will be no refund for any performed services
In relation to my initial and subsequent treatments I advise that:*

I have not had unprotected sun exposure (including tanning beds and fake tan creams) in the last 2-4 weeksI have no history of seizures and I have disclosed all known allergies (eg. Latex, etc)I am not taking any medications causing photosensitvity (prescription/non-prescription) eg. St Johns Wort, Anti-coagulants, etc.I do not have a history of keloid & hypertrophic scar formationI do not have active infections/immunosuppressionI do not have Herpes I or II - in the areas to be treatedI have not used Tretinoin (Retin-A) within the last 2 weeksI have not had any Laser Resurfacing within the last 6 monthsI have not used Oral Isotretinoin/Accutane - within the last 6 monthsI have advised my clinician if I am diabeticI am not pregnant, breastfeeding and not taking any medication which may affect treatment outcomesI have received the Pre- and Post-care Information Sheet and agree to adhere to all of the recommendations within
Consent

I have read all of the above and have had taken the opportunity to have any questions satisfactorily answered before agreeing to undertake this treatment.

Note: Do not sign this form until you have read and understood all of the above.
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