Chemical Treatment Consent Form

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• Read this consent form thoroughly and check the circle of each section. Discuss any questions with your skin care professional before you initial. Your signature and date at the bottom constitute giving your consent to have a treatment.
• I understand that there are no guaranteed results from this treatment. Many variables exist such as age, degree of sun damage, on going sun exposure, smoking, excessive alcohol intake, climate, diet, water intake, skin thickness and sensitivity. I understand that I may or may not visibly peel and that each case is individual.
• I have been candid in revealing any condition that could prohibit this treatment such as cold sores, pregnancy, and use of hormones (birth control and HRT), recent facial surgery or laser resurfacing, recent use of retinol, within the past 5 days, or Accutane within the past 6 months. Any immune system diseases including but not limited to Lupus, HIV, Hailey Hailey, or any and all autoimmune diseases.
• Regardless of precautions taken, I acknowledge the possibility of an adverse reaction to the peel and accept sole responsibility for any medical care that may become necessary. I will immediately notify the esthetician performing the treatment of any adverse reactions.
• I will not scratch, pick, or scratch the treated skin.
• I understand that direct sun exposure and use of a tanning booth is prohibited during a post treatment of 14 days and that there is a mandatory use of a (minimum SPF 15) mineral sunscreen protection daily to be reapplied every 3 to 4 hours or as directed by the esthetician.
• I understand that to achieve maximum results the recommended home care routine must be followed. I understand that if I alter the routine or use products not recommended by the esthetician the results could be altered or inhibited. I also understand that it may take several treatments to obtain the desired results.
• I understand that the following side effects or complications can occur:
• 1. Redness
  2. Discomfort
  3. Redness and swelling
  4. Hypopigmentation
  5. Itching or irritation
  6. Skin peeling or flaking up to 14 days after the procedure
  7. Infection
  8. Hyperpigmentation
  9. Acne breakouts
• I understand the goals of the treatment as well as well as the limitations and possible complications.
• The esthetician has provided the information and has ansered all of my questions concerning this procedure. I clearly understand the above information.
• By checking this box you agree to the terms of the Chemical Treatment Consent Form
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  Name
• Date
  
  Date Format: MM slash DD slash YYYY