Chemical Peel Consent Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Please read and check the box once you understand each statement. Consent Checkoff* I have been given the Skin History Questionnaire and have read and answered the questions thoroughly. I have discussed any further questions that I may have with my skin care specialist. I am aware and acknowledge that there is a rare possibility of an allergic reaction. I have discussed thoroughly with my skin care specialist any such reactions and understand them, I have had a patch test and it is negative. I am willing to forego a patch test, but understand there could be an allergic response. I have been advised that my treatment is a noninvasive, light epidermal exfoliation consisting or any of the following: salicylic acid, AHAs, retinol, TCA, resorcinol, or red wine vinegar acid. These are superficial procedures. The use of the above ingredients stimulates the skin to generate new skin cells and new collagen formation and increases the blood circulation and flow to the skin. It does not replace deep chemical peels, laser resurfacing or plastic surgery. I acknowledge that during application I will notice a warm sensation and the skin may tingle, sting or burn. 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 seven, the skin will peel. I am not to pick or peel the old skin. Pulling or picking skin may lead to infection (which will require treatment with topical antibiotic) or surface scarring. I may experience some breaking out after a peel. I acknowledge that I will avoid direct sun exposure and tanning beds during this procedure and will apply a sunscreen daily. Skin peels may lighten hyper-pigmented skin, and I acknowledge that there is NO GUARANTEE that dark discoloration of the skin known as melasma will be reduced or faded. I am aware that there could even be an increase of uneven color from this procedure. I acknowledge that I have not been on Accutane during the past six months. I acknowledge that I have not been using Retin A or Renova for the past two weeks. I acknowledge that if I am prone to cold sores (herpes), I may need a prescription from my physician prior to having the peel. I am aware the treatment could bring about cold sores. I acknowledge that I am not aspirin-sensitive or, if I am, I have discussed this with my skin care specialist and understand that there could be a reaction. I acknowledge that I will not have any other skin care procedures of any sort until I am passed by my skin care specialist to do so. Signature Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY
