Chemical Peels

Client Name

First NameLast Name

Date of Birth*

Informed Consent for Chemical Peels

INSTRUCTIONS
This is an informed consent document which has been prepared to assist your Skincare Specialist to inform you about skin peel and skin treatment procedure(s), its risks, and alternative treatment.
It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent.

DISCLAIMER
Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.
However, informed consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Skincare Specialist may provide you with additional or different information which is based on all the facts in your particular case and the state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.

Contraindications to all peels: If you have any of the following, a peel should not be done at this time and you must notify your Skincare Specialist immediately;

Use of Accutane in the last 6 months
Active herpes simplex (cold sores)
Facial wards
If you are now pregnant, think you might be pregnant, or are trying to become pregnant
If you form keloid or hypertrophic scars
If you had a history of sun allergies
Prior bad reaction to a peel
Recent radiation treatment for cancer
Sunburn or significant sun exposure in the last two days
Surgery or cryosurgery within the last month to the area that you plan to have peeled
Allerigic to Resorcinol
Allergies to salicyic acids
Blood vessel disease
Diabetes
Inflammation, irriation or infection of the skin
Influenza
Varicella (chicken pox)
Kidney or Liver disease

What To Do Before Your Peel

Do not apply Retin-A, Renova, Tazorac, and/or Differin 2 weeks prior to and 2 weeks after your peel, to the treatment area or as instructed by your Skincare Specialist at Skin Facial Bar.
Do not sun tan or use the tanning bed 2-4 weeks prior to and 2-4 weeks after your treatment.
Stop any type of depilatory treatments (waxing, depilatory creams) to the area of treatment, 2 weeks prior to and 2 weeks after your peel.
Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of treatment, 2-4 weeks before and 2-4 weeks after your peel or as instructed by your Skincare Specialist at Skin Facial Bar, LLC.

Post Treatment Care

When cleansing, do not scrub. Use a gentle cleanser directed by your Skincare Specialist at Skin Facial Bar, LLC.
With any peel, your skin may start to peel 1-3 days after the peel and continue to peel for 2-5 more days; however, it is also possible your skin may not peel at all.
Do not peel, pick or scratch the treated area, as this may result in scarring.
Apply Aquaphor to dry flaky areas or as directed by your Skincare Specialist at Skin Facial Bar, LLC.
Do not have any other facial treatments for at least 2 weeks after your peel or until the skin is smooth and back to normal.
Follow any additional and all instructions given to you by your Skin care Specialist.
Always wear your sunscreen; apply a sunscreen with SPF 30 every morning

After Peel: Clients may have tightness and smoothness immediately post-peel. You may experience peeling 1-2 days after treatment and can extend up to 7 days. Transient hyper-pigmentation and superficial crusting is possible in areas of inflamed acne. Skin type III may experience darkening after peel due to increased shedding of the outer layers. Minor side effects may include, but are not limited to superficial crusting, edema and temporary bruising in the lower eyelid areas, hypo-pigmentation, temporary dryness and hyper-pigmentation, all which typically resolves quickly

Name*

First NameLast Name

Date of Birth*

Date

Are you Pregnant or Nursing?*

YesNo

Are you allergic to Aspirin?*

YesNo

*Please read the following statements carefully and indicate your understanding and acceptance.

I acknowledge that I have not been on Accutane (isotretinoin) within the past six months.

The Skincare Specialist at Skin Facial Bar LLC has explained to me the treatment process and it may include various acids which are called chemical peel. I understand that side effects may include, but are not limited to, increased color, decreased color, infection, pain, bleeding, swelling, scarring or damage to nearby structures, nerves, drug reactions or unforeseen complications.

I am undergoing this peel in an effort to improve my skin texture and color. I understand I may achieve some improvement in my fine wrinkles as well, but no guarantee has been made to me regarding my level of improvement from this peel. The Skincare Specialist at Skin Facial Bar LLC has explained to me that I may need several of these peels to achieve optimal results.

I understand that there is a possibility that this procedure will fail or be unsuccessful or need to be repeated or may require additional treatments.

I have read the instructions provided as to how to care for my skin prior to and following this Procedure and agree to abide by it. I understand that proper sun protection including, but not limited to, the faithful use of broad spectrum UVA-UVB sun block with SPF 30 is vital to proper aftercare and the reduction of risks of undesired side effects.

I understand my responsibility for properly fulfilling the appropriate aftercare instructions as explained by the Skincare Specialist at Skin Facial Bar, LLC. I hereby release and hold harmless my Skincare Specialist, Skin Facial Bar LLC and any of its employees, their suppliers from any consequences resulting from my failure to properly fulfill such aftercare instructions.

Since multiple treatments may be required, this consent continues for all subsequent treatments by the Skincare Specialist at Skin Facial Bar LLC regardless of the time between treatments

I am aware and acknowledge that there is a possibility of an allergic reaction. I have discussed thoroughly with my skin care specialist any such reactions and understand the care that would be necessary in the event of a reaction. I have had a chemical peel patch test done.

I acknowledge that if I am prone to cold sores around the mouth, I will inform my skin care specialist and may need to use an anti-viral medication before the peeling treatment. (Peels may exacerbate the herpes virus.)

I acknowledge that immediately after the peel, my face may appear frosted or sunburned and by day two, the skin may darken in color, feel tighter and be more sensitive. Days two through approximately seven, my skin may slough.

I may experience some breakouts after the peel (for a period up to seven days) that normally disappear. Chemical peels make extractions of the comedones easier and the acne will ultimately improve if I continue treatment as directed by my skin care specialist.

I acknowledge that pulling or picking skin may lead to infection or scarring.

I am aware that on rare occasions the peel can penetrate deeper in certain areas, causing a crusted scab to form. I understand that if this area is not treated appropriately it could become infected and possibly lead to the formation of a scar. It is my responsibility to contact Skin Facial Bar LLC if any crusted areas form or if my skin does not look and feel completely normal within one week after my peel. I acknowledge this and desire that this product be applied to my skin.

I understand and am willing to comply with all pre and post care instructions. This procedure has been explained to me and my questions regarding such treatment, its alternative, its complications and risks have been answered. I have been asked at this time whether I have any further questions about this procedure and I do not.

I understand the procedure and accept the risks, and request that this procedure be performed on me by a Skincare Specialist at Skin Facial Bar LLC. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.I release Skin Facial Bar, LLC, and all of its employees/staff, from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all information detailed above.

Signature*

Date*

Date

Skin Facial Bar LLC | 8300 Old Courthouse Rd. Suite #240, Vienna, VA 22182 | 703-827-3777

Informed Consent for Chemical Peels

Chemical Peel Consent