Chemical Peel Consent Form I understand everything explained to me in my consultation including the following that may have a bearing or possible side effect on this procedure during and post treatment: Accutane use, pregnancy, nursing, history of cold sores, allergies, aspirin allergy Hyper/Hypopigmentation Contact Dermatitis, inflammation(redness), edema(swelling), skin irritation(itchiness) Temporary sensation of heat and itchiness immediately following treatment PEELING: I understand that I may or may not actually peel and that each treatment is individual. I understand that the degree of peeling does not correlate with the degree of improvement. CONDITIONS OF TREATMENT: I agree to refrain from the following activities for 14 days following my treatment: Sun/tanning bed,microdermabrasion, laser hair removal, photo facials, chemical peels, laser/rf treatments, use of retinols, use of mechanical exfoliants, use of topical AHA/BHA and all other exfoliant topical skin care products I agree to refrain from the following activities for 7 days post: Waxing, threading, all use of depilatories, neurotoxin injections, dermal filler injections, tanning products, acne topical treatments I agree to disclose names of any prescription/non prescription products I am using. I agree to follow post treatment protocols recommended by my skin care professional. I agree to use a professional, medical grade sun protection SPF 30+ for a min of 14 days. Limitations to treatment: I understand there are no guarantees as to the results of this treatment due to many variables including age, skin condition, sun damage, smoking, climate etc. I understand that this treatment is cosmetic and that no medical claims are expressed or implied. I understand that to achieve max results I may require several treatments and the suggested at home skin. COMPLICATIONS: I understand that although complications are rare, they do occur and prompt treatment is necessary. In the event of complication I will contact the skin care professional who performed my treatment. I hereby certify that all the information I have provided has been accurate and truthful. I agree to follow post treatment care instructions provided to me. Name First Last Date of Birth Date Format: MM slash DD slash YYYY GenderFemaleMaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Are you currently using or have you used Accutane in the last six months?*YesNoAre you pregnant or nursing/lactating?*YesNoDo you have a cold sore today (herpetic breakout?)*YesNoDo you have any allergies? If yes, please list:*Yes, please listNoAllergies:RELATIVE CONTRAINDICATIONS: Have you had a chemical peel within the last 14 days? Have you had laser hair removal within the last 14 days? Have you had a photo facial treatment within the last 14 days? Have you had radio frequency skin tightening within the last 14 days? Have you had waxing, threading, or any other form of hair removal in the last 7 days? Have you had Botox in the last 7 days? Have you had any dermal filler injections in the last 3 weeks? Have you been exposed to the sun in the last 3 weeks? Have you used a tanning bed in the last 3 weeks? Are you currently using sunless tanning products? Are you using any prescriptions or non prescription retinoids? (eg.retinol, Retin-A, Tazorac) Are you using any AHA/BHA skin care products? Are you using any prescriptions topical medications at this time? Do you wear contact lenses? Do you have permanent makeup? Do you participate in aerobic physical activity? Have you ever had a cold sore? Have you ever used any skincare products that caused adverse reaction? Please select all that apply. What is the ethnic background of your parents?What are the skin concerns that you would like us to help you with?Signature*Date* Date Format: MM slash DD slash YYYY Location*LocationPitt MeadowsPort MoodyELECTRONIC CONSENT*AgreeeDisagreeThird ChoiceELECTRONIC CONSENT: Please select your choice below. Clicking on the "agree" button below indicates that: • I have read and fully understand this agreement and all information detailed aboveCAPTCHA
