The Perfect Derma Peel Consent Form

The Perfect Derma Peel is a medium depth, medical grade chemical peel suitable for all skin types.The peel contains Tricloroacetic Acid (TCA), Retinoic Acid, Kojic Acid, Salicylic Acid, Phenol, Glutathione and Vitamin C.

Contradictions:

• Patients who are pregnant or breast feeding

• Patients with an allergy to any peel ingredient listed above, or to aspirin

• Patients who have used Accutane within the past 4 months

• Patients who have open wounds, sunburn, infected skin, cold sores or lesions.

• Patients with a history of cold sores (herpes simplex) may be given an antiviral 3 days prior to the peel

• Patients who have recently had treatments such as waxing, electrolysis or chemical exfoliants

• Patients who are undergoing chemotherapy and/or radiation therapy

• Patients with a history of an autoimmune disease or any condition that may weaken the immune system

By signing this form, you are agreeing to the following:

Prior to receiving treatment, I have informed my medical professional about any medications or health conditions that may contraindicate this treatment. I understand that there might be some discomfort such as stinging, redness, burning, itchiness or tightness during and a week after the treatment. I understand that it is important not to pull, pick at or remove peeling skin forcibly. I understand that there is no specific guarantee as to the final results of the peel, and that I may require more than one treatment for optimal results.

I understand that while complications are extremely rare, they may occur. In the event of a reaction or complication, I agree to immediately contact my medical professional for follow up care. Occasionally hyper pigmentation or hypo pigmentation may develop which can persist for weeks or months after the treatment. I understand that post peel care includes use of Mineral Perfection Tinted SPF 30 or an SPF 30 or above and will avoid sun exposure during the exfoliation process. I understand that extended sun exposure, including use of tanning beds, is prohibited both before and after

The Perfect Derma Peel treatment.

Avoid sweating excessively or use of steam/sauna for 3 days post peel. I understand that this is an elective procedure and is nonrefundable. I understand that no other chemical peels or medical device treatments are to be performed on my skin until my medical professional releases me to do so. I authorize the taking of clinical photographs for my medical record, to be used for scientific purposes both in publication and presentations. I understand my identity will be protected.