Consent to Treat Form

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: Pregnancy, recent facial surgery, allergies, tendency to cold sores/fever blisters, use of topical ingredients that contain retinal, AHA's or the like, use of acne medications or other skin medications including Retin-A, Accutane, Differin, Tazorac or the like.

I understand that there may be some degree of discomfort; i.e. stinging, pin pricking sensation, hotness, or tightness.

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I understand there are no guarantees as to the results of this cosmetic treatment, due to many variables, such as age, condition of the skin, sun damage, smoking, climate, etc. I understand I may or may not actually peel, that each case is individual.

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I understand that to achieve maximum results, I may need several treatments.

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I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In an event of any complications, I will immediately contact the aesthetician that performed the treatment.

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I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sunblock with a minimum of SPF 30 is mandatory.

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I hereby agree to all of the above and agree to have this voluntary treatment performed on me. I have informed the aesthetician of any and everything that could have bearings on my treatment today. I have read and further agree to follow all pre and post peel care instructions as I am directed.

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