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Form - general consent.doc

The Skin Institute at Savannah Plastic Surgery
The Skin Institute Clinical Treatments may consist of waxing, tinting, cleansing, mechanical and/or chemicalexfoliation, steam, extraction with sterile instruments, tonic rinsing, mask or superficial peeling application,superficial sanding with aluminum oxide crystals and an anti-inflammatory treatment. Clinical treatmentstake approximately 15 minutes to one hour and are designed to cleanse, exfoliate, and restore the skin asmuch as possible in the allotted time.
PLEASE READ CAREFULLY
Aggressive use of glycolic, benzoyl peroxide, retinoic acid and vitamin C home care products as well as
over-scrubbing, picking and sun exposure can cause temporary dryness, irritation and dark spots following
the procedure.
Patients that have had Accutane therapy, chemical hair or face treatments may be more prone to posttreatment complications including burns, scabbing and patches of hyperpigmentation. Please advise youresthetician if you have had any of these treatments within the past two weeks to six months.
Patients that have used Retinoic Acid products within 48 hours of their scheduled treatment may not have a30% Glycolic Peel or a Salicylic Acid Peel. Please inform your esthetician or physician if you are takingAccutane or have used Retin-A so that you may be rescheduled.
Wait at least 24 hours before applying acne medications and glycolic-based products or using scrubs ordepilatories. Since the skin may be more sensitive to extraction discomfort during a woman’s menstrualcycle, please schedule accordingly.
Rarely, an allergic reaction occurs. Treat allergic reactions the following way:Call the office (912) 351-5050. SPSA Physicians are on call 24 hours a day. Temporarilydiscontinue the use of all products, except sunblock. Apply cold compresses hourly. Reactionsymptoms usually disappear in a day or two.
Dryness, sensitivity, redness, small scabs, small cuts, and flaking are possible temporary side effects of aMicroPeel, MicroPeel Plus, waxing, Microdermabrasion or clinical facial treatment. Mild, superficialtemporary dark spots will occasionally occur after the extraction of older or deeper lesions and will faderapidly.
YOU MUST AVOID THE SUN and use your prescribed post-treatment protocol exactly as directed.
This will reduce the formation of new lesions and help fade and exfoliate existing spots.

Your Skin Care Specialist will wear surgical gloves throughout the procedure. Everything else used will bedisposable or sterilized.
CONSENT FOR TREATMENT
By signing below, I hereby consent to a clinical facial treatment or waxing procedure (MicroPeel, MicroPeel
Plus, Microdermabrasion or Clinical Facial Treatment). This consent will serve as my consent for future
treatments. I have informed the clinic of any health problems I may have, and any and all medications I am
taking, especially Accutane or Retinoic Acid Creams.
Patient’s Name: (Print) __________________________________ Patient Signature: ________________________________________________________________
Witness: ________________________________________________________________________

Source: http://www.savannahplasticsurgery.com/documents/SI-generalconsent.pdf

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