, have read the below information and initialed each section to indicate
that I fully understand what to expect. If I have any questions or concerns, I will address these with my skin
therapist. I give permission to my skin therapist,
, 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.
I understand that I should not have a chemical peel if I intend to continue to have excessive sun exposure.
It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and
will require regular use of sunscreen.
I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my therapist.
My expectations are realistic and I understand that the results are not guaranteed and that for maximum results,
more than one application may be required. The rate of improvement of my skin depends on my age, skin type
and condition, degree of sun/environmental damage, pigmentation levels, or acne condition.
I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree
to inform the skin professional immediately if I have concerns or am overly uncomfortable during treatment or
after I return home.
I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for
following home regimens that can minimize or eliminate possible negative reactions, including recognizing the
importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions.
I agree to use a moisturizer specifically recommended by my therapist and I acknowledge that I have been
informed of the possible negative reactions (intense erythema, welts, scabs) and the expected sequence of the
healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have additional
questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my therapist immediately.
I understand the potential risks and complications and have chosen to proceed with the treatment after careful
consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that
this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I
have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion
to have any questions answered.