Facial/Microdermabrasion/Chemical Peel Consent Form
Name
First Name
Last Name
I understand that this is a cosmetic treatment and that no claims are expressed or implied. I understand that to achieve maximal results, I will need more than one treatment and I need to follow the maintenance home protocol.
*
Initials
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.
*
Initials
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 Patricia Solis.
*
Initials
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.
*
Initials
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 three to five days prior to the treatment with exception of Accutane which must be discontinued for six months prior. That means, absolutely no retinols, (vitamin a),scrubs, or actives as explained by my esthetician prior to treatment.
*
Initials
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 Patricia Solis and the additional post care products may be required.
*
Initials
PHOTOGRAPHS: I give permission for photographs to be used by Patricia Solis for educational plus promotional purposes. Complete patient confidentiality will be maintained at all times.
*
Initials
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 inform Patricia Solis of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.
*
Initials
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.
*
Submit
Should be Empty: