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Chemical Peel Consent

 

 

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy(if so consult physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as: Trentinoin, Retin-A, Accutane, Differin, Tazorac, Avage, EpiDuo, or Ziana.

 

I understand there may be some degree of discomfort such as stinging, pin-prickling sensation, heat, or tightness.

 

I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc.

 

I understand I may or may not actually peel and that each case is individual. I understant that the amount of peeling does not correlate with degree of improvement.

 

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.

 

I understand that to achieve maximum results, I may need several treatments.

 

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 the physician/clinician who performed the treatment.

 

I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging.

 

I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum of SPF 30 is mandatory.

 

I have not had any other chemical of any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location.

 

I understand that I should follow my clinician's recommendations for post-procedure skin care to minimize side effects and maximize results.

 

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-peel care instructions as I am directed.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you pregnant or lactating?*
No
Yes
Are you using any topical acids or retinols?*
No
Yes
Have you used accutane in the last year?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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