Chemical Peel Treatment Consent

 

DESCRIPTION OF TREATMENT

A chemical peel can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance of hyper-pigmentation. Layers of product are applied based on your unique skin composition and needs. Multiple treatments may be required in order to obtain optimal results. Treatments are typically spaced 2-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.

CONTRAINDICATIONS

  1. Pregnancy/Lactating

  2. Herpes Simplex (cold sores or fever blisters). May require anti-viral medication prior to treatment

  3. Extensive sun or tanning 3 days prior and 3 days post treatment

  4. Isotretinoin (Accutane) in the past 6 months to 1 year

  5. Topical retinol products in the past 2 weeks

  6. Waxing of area to be treated in the past 7 days

  7. Any other chemical peel within 14 days of the treatment

  8. Skin must be healthy and intact

  9. An allergy to aspirin (salicylates)

POSSIBLE RISKS / COMPLICATIONS

  1. Mild to moderate discomfort or pain

  2. Slight redness or swelling

  3. Sun sensitivity

  4. Skin sensitivity

  5. Pigment changes

  6. Scarring

  7. Allergic reaction

  8. Bacterial infection

PATIENT CONSENT

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

I consent and authorize IKAL Spa + Face Salon to perform one or more chemical peels on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release IKAL Spa + Face Salon from all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the future as well.