, to perform the chemical treatment
we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this
treatment. I understand my skin therapist will take every precaution to minimize or eliminate negative reactions
such as blisters, sores, or other reactions, as much as possible. I do understand that, very rarely, permanent
damage occurs. I have given an accurate account of any over-the-counter or prescription medications that I use
regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A,
Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics,
or other chemical peels or skin treatments that I have not disclosed to my skin therapist. I am not ingesting or
using topically any other over-the-counter product or prescription medication/agent that has not been disclosed
to my skin therapist. I am not presently pregnant or lactating and I am over the age of eighteen (18). I have not
had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently
waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring,
diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with
the positive outcome of this treatment.