Eastlakeacupuncture.org

East Lake Acupuncture & Wellness, LLC
407-738-7412
INFORMED CONSENT FOR ACID PEEL
, agree to the use of glycolic/salicylic/TCA/Jessner acid peel on my face and/or neck/chest. _____ I have/have not had an acid peel before. My last peel was approximately ______ months/days/weeks/years ago. ______ I understand the treatment is a light, safe, cosmetic peeling program and for the best results, should be performed in a series of peels over a period 90 days. _____ The peel can be repeated as often as every two weeks. _____ The skin should be free of irritation at the beginning of each peel and I understand that I must inform my aesthetician if I have a sunburn, rash or any other skin irritation, no matter how small or insignificant I may believe it to be, so that she may make a determination as to whether or not it’s safe to proceed with the treatment. _____ I understand that most patients experience no adverse side effects whatsoever, however, each person’s skin can react differently and there is always the potential for post-peel irritation. _____ Possible side effects may range from mild swelling, redness, mild scabbing to peeling; all of which are temporary. Normal after-effects of a peel are a “tight” sensation on the skin, a dry or “wind burned” feeling that may last several days and possible redness. _____ I will contact my aesthetician immediately if any of the side effects occur or persist or if I have any questions or concerns regarding my treatment or follow up care. _____ Peeling should begin anywhere from 2-7 days after the peel. I understand that I should NOT pull off any bits or pieces of skin as it could cause scars! _____ I must not and have not used Accutane™ (or a similar product) for six months prior to receiving this treatment and I must not and have not used Retin-A™ (or a similar product) for 48 hours prior to receiving this treatment. This treatment must not be performed if there is skin irritation, eczema, inflammation or dermatitis. _____ I have been provided with written, post-peel instructions. I have read, initialed, and understand the above information and I authorize the Jeannette Kerns, licensed Facial Specialist, to perform a chemical peel. Aftercare Instructions
**WEAR SUNSCREEN. Your skin’s natural “acid mantle” has been temporarily destroyed, leaving you unprotected against harmful rays. You will burn easier for the next 3-5 days and need to wear sunscreen. Even if you’re driving or near windows (this should apply to live in general, not just with a peel).
Avoid using any alpha hydroxy acid product (such as glycolic or lactic acid) or salicylic acid
product for 12 hours.
Women: Avoid waxing, electrolysis or other methods of hair removal for a minimu m of 48 hours
(preferably 3 to 5 days).
Men: Do not shave immediately before or after your peel.
Do not apply any skin care product or makeup to your face (except for lipstick and eye makeup)
for three hours after your peel. After this time period, you may use a moisturizer.
Avoid using alpha hydroxy acid products (such as glycolic or lactic acid) or salicylic acid products
until the day after your peel.
Avoid using Retin-A or other topical acne medications until the day after your peel.
The evening following your peel:
 Gently cleanse your skin and pat dry.
The day after your peel:
 Use a gentle cleanser or alpha hydroxy acid cleanser (if recommended by your physician)  Apply any topical medication, moisturizer and sunscreen advised by your physician.  Apply makeup, if desired.
If/when peeling begins
 For the first few weeks after a peel, almost every patient will experience slight dryness or flaking which is actually the peeling of old skin layers. This is beneficial and a moisturizer  Do NOT pick or pull at bits of peeling skin. It’s best to let it fall off on its own; however, for large pieces, you can use cuticle scissors to clip off any bits that are irritating you. When I can use my exfoliation products?
 You can use a gentle exfoliation product 5 days after your peel. Use as directed and only use exfoliation products specifically for the face and for your skin type. Your aesthetician will help you choose a product if you do not already have a favorite.

Source: http://www.eastlakeacupuncture.org/Informed_consent_for_acid_peel_and_take_home_instructions.pdf