Informed Consent- Chemical Peel

1. Have you had a chemical peel before?
The instructions provided in this informed consent should be followed by all patients receiving a Chemical Peel. You will be asked to sign this form acknowledging that you have read and understood all of the above information provided.
DO NOT HAVE A CHEMICAL PEEL IF: you are suffering from active cold sores, have skin with open wounds, have a sunburn, you have excessively sensitive skin, have dermatitis or inflammatory rosacea. Consult your skin care technician if you have any history of herpes simplex.
2. Have you used Accutane or any retinols in the past 6-12 months?
3. Are you allergic to salicylates (aspirin products)?
4. Are you allergic to shellfish?
I understand that this release form is for any and all related chemicals applied by a skin care specialist at The Spa Society and complications could potentially occur listed below.  Skin infection (pus, oozing, fever). Treatment or P.I.H (Post-Inflammatory Hyper Pigmentation).  Appearance of a cold sore on the lips or any other portion of the peeled area.  Allergic reaction, acne, or irritation to any of the creams or medications.  Wind or sun sensitivity; sun may increase the possibility of swelling and redness.  Extreme reactions, such as permanent scarring or keloids. Possible Scaling, scratches on the skin.  Increase or decrease in skin pigmentation, which does not blend with normal skin after healing from  Treatment or P.I.H (Post-Inflammatory Hyper Pigmentation). PATIENT CONSENT: The Skin Care Specialist/or another trained professional has explained to me the possible complications from the proposed chemical peel and I have had sufficient opportunity to ask questions. I understand that the chemical peel treatment causes a burning sensation that can last several minutes. Multiple peels may be necessary to achieve the desired results, especially with light chemical peels, depending on my skin type and the nature of my skin problem. The degree of clinical improvement that is observed after chemical peeling is variable, as medical treatment is not an exact science. It was explained to me in full that importance of application of sunblock during and after treatment. After receiving and understanding in full all the information presented above, I freely give my consent to undergo the chemical peel procedure. I also consent to the taking of medical photographs to track my treatment progress. I understand that this procedure is cosmetic and that payment is my responsibility. My questions have been answered by the doctor and her staff to my complete satisfaction. I accept the risks and complications of the procedure. I hereby release The Spa Society from any liability for this treatment and further chemical treatments.
Sign Below: