Chemical Peel Consent Form
Prior to receiving treatment, I have reviewed and signed the Client Proﬁle given to me by my physician/skin care professional. I have been truthful in disclosing information that may have bearing on this procedure including the following:
POSSIBLE ADVERSE EVENTS
I have been informed that the following may occur post treatment: • Hyperpigmentation/hypopigmentation (to minimise the chance of this occurring, the proper post procedure must be followed) • Allergic reaction: I also understand that exposure to different ingredients found in the treatment and associated home care products may result in an allergic reaction. If an allergic reaction occurs, I will immediately discontinue use of all professional treatments and AlumierMD home care products and consult my skin care specialist • Contact dermatitis, inﬂammation (redness), edema (swelling), skin irritation (itchiness) • Temporary sensation of heat and itchiness immediately following treatment
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 post-treatment:
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 maximum results, I may require several treatments.
I understand that although complications are rare, they do occur and prompt treatment is necessary. In the event of complications, I will contact the physician/skin care professional who performed my treatment. I hereby certify that all the information that I have provided has been accurate and truthful. I acknowledge the above adverse events, limitations and complications. I further acknowledge that these adverse events, conditions, limitations and complications have been explained and that I accept and consent to treatment. I agree to follow all post treatment care instructions provided to me. I acknowledge that I have been provided with adequate time to read, understand and accept the above adverse events, limitations and complications.
I agree to refrain from the following activities for 7 days post treatment:
I agree to disclose the names of all prescription and non-prescription products that I am using. I agree to follow all post-procedure protocols recommended by my skin care professional. I agree to use a professional, broad spectrum sun protection product (SPF 30 or higher) for a minimum of 14 days post treatment.
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Signed by Nina Bal
Signed On: 8th January 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Chemical Peel Consent Form
Agree & Sign