I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had suf cient opportunity for discussion to have any questions answered. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.