INFORMED CONSENT FOR CHEMICAL PEEL TREATMENT
ALL INFORMATION IS CONFIDENTIAL

I understand there are contraindications to this treatment, including but not limited to the:

  • Use of Isotretinoin (Accutane) in the past 6 to 12 months.

  • Use of prescription topical Keratolytics in the last past 7 days: (Retin-A, Renova, Azelex (Azelaic Acid), Tazorac (Tazarotene), Differin (Adapalene).

  • The current use of Hydrocortisone

  • Any known allergies or sensitives or ingredients of peels (see page 2).

  • Allergy to Aspirin (Salicylic Acid).

  • Currently under the supervision of a Dermatologist for a skin disorder.

  • Autoimmune disorder.

  • Sunburn.

  • Active facial rashes.

  • Active cold sores (herpes simplex).

  • Open lesions of the face.

  • Recent facial surgery.

  • Infectious disease

  • Pregnancy/ breastfeeding

 

I certify that I am not taking any of the above medications or experiencing any of the above conditions. While every precaution is taken, I understand the risks and consent to receive treatment today.

Thanks for submitting!