Facial Sculpting

Chemical Peel Consent Form


FULL DISCLOSURE

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:

  • Accutane use (if so, do not do treatment)
  • Pregnancy  (if so, do not do treatment)
  • Nursing/lactating
  • History of cold sores
  • Allergies
  • Aspirin allergy

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

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 post-treatment:

  • Sun or tanning bed exposure
  • Microdermabrasion
  • Laser hair removal
  • Photofacials
  • Chemical peels
  • Laser/RF skin treatments

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.

COMPLICATIONS

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:

  • Waxing threading, and all use of other depilatories
  • Neurotoxin injections (eg. Botox, Dysport)
  • Dermal filler injections
  • Use of retinoids
  • Use of mechanical exfoliants
  • Use of topical AHA/BHA and all other exfoliant topical skin care products
  • Use of sunless tanning products
  • Acne topical treatments

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.

TREATMENT LOG

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Signed by Nina Bal
Signed On: 8th January 2020

Signature Certificate
Document name: Chemical Peel Consent Form
Unique Document ID: dd7b551ecad89558aee4df30162df8bc0446f275
Timestamp Audit
7th November 2019 8:06 am BSTChemical Peel Consent Form Uploaded by Nina Bal - info@facialsculpting.co.uk IP 51.179.98.227