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This is the waiver form for the VI Peel procedure. 

The VI Peel® contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel® will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin. Contradictions: • Patients who are pregnant or who are breast feeding • Patients who have an aspirin, hydroquinone or phenol allergy • Patients who have used oral isotretinoin (Accutane) within the past 6 months • Patients who have active cold sores, warts, open wounds or history of herpes simple • Patients who are undergoing chemotherapy and or radiation therapy within 6 months • Patients with a history of an autoimmune or liver disease/disorder as well as any condition that may weaken their immune system

Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.

I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during and up to a week after the procedure.

I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.

I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.

I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.

I understand that maintenance of VI Peel® treatments are necessary to maintain results as well as the recommended VI Derm® skin care regimen and SPF 50+.

I understand that extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®.

I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub steam room and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)

I understand that I must protect my skin with VI Derm® SPF 50+and avoid sun exposure during the 7 day exfoliation process.

I understand that this is an elective cosmetic procedure.

I understand that no other chemical peels, facial machine brushes or medical device (laser, IPL, etc.) treatments may be performed on my skin until my physician/clinician releases me to do so. 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.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Select all that you are seeking improvement upon:
Pigment
Aging
Acne
Rosacea
Other
Are you pregnant or breastfeeding? If yes, are contraindicated for a chemical peel.*
No
Yes
Do you have permanent makeup?*
No
Yes
Do you wear contacts?*
No
Yes
Have you recently had facial or body waxing or used at home depilatories?*
No
Yes
Do you currently have wind burned skin?*
No
Yes
Do you have extended outdoor plans in the next 7 days? If yes, are contraindicated.*
No
Yes
Do you plan to participate in vigorous exercise in the next 72-96 hours?*
No
Yes
Have you had any active skin care treatments in the past 21 days?*
No
Yes

If yes, how long ago?

List all Topical products applied in the last 7 days:

List all prescription medications currently taken and in the past two weeks: (Patient must be off Accutane for 6 months prior to peeling)
Have you recently undergone any surgery or laser treatments in the area to be treated?*
No
Yes

If yes, provide detail:
Do you receive injectables? (Botox, Fillers)*
No
Yes
Do you develop cold sores?*
No
Yes

Do you have any known allergies or sensitivities? (Please list)

Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, Other.)
How would you describe your skin?*
Sensitive
Normal
Resilient
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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