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 many variables such as age, conditions of the skin, sun damage, smoking, and climate. I 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 very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact I agree to refrain from tanning or excessive sun exposure while I 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 sun block protection with a minimum SPF 15 is mandatory. I have revealed any medical conditions that may effect 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 five days prior to the treatment with exception of Accutane which must be discontinued for 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 of properly fulfilling the appropriate after care instructions as explained by for educational plus PHOTOGRAPHS: I give permission for photographs to be used by (please initial promotional purposes. Complete patient confidentiality will be maintained at all times. Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also informof 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.