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Microsoft word - document

INFORMED CONSENT
FOR MICROPEEL TREATMENT

I, _______________________________________, consent to and authorize the certified staff of
BIOAesthetics Skin Enhancement and Rejuvenation, LLC to perform professional skin
exfoliation and chemical peel (MicroPeel).

I understand the purpose of a MicroPeel is to help improve the vitality and texture of my
skin through superficial removal of dead skin cells. I understand there is a possibility of
short-term effects such as reddening, blistering, scabbing, and temporary discoloration of
the skin, as well as rare side effects such as scarring and permanent discoloration
.
For Microdermabrasion exfoliation treatments I will discontinue all AHA’s, Glycolics, Retin-
A, Renova, Retinol A, or any exfoliating products for up to 72 hours post-procedure. I understand that I must use hydrating and soothing antioxidants for healing, and ice for swelling and inflammation reduction. Also, I understand there should be no sun exposure for 72 hours and the use of an SPF 30 at all times during treatment duration is advised. ____Initial
I confirm that I am not pregnant at this time. I have not had deep chemical or mechanical peeling within the last 2 weeks preceding treatment. ____Initial
I will avoid collagen injections for up to 10-14 days before and to avoid Botox injections for up to 7 days before any Microdermabrasion treatment and agree to these restrictions. ____Initial
If I am prone to Herpetic outbreaks, I will see my physician about a prescription for ____Initial
I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. ____Initial
Possible side effects may include, but are not limited to: Mild redness, extreme redness, bruising, local swelling, stinging, tenderness, dry skin, flaking, lightening or darkening of the skin, infections, pimples, bumpy appearance, and cold sores. Most side effects are temporary and generally subside within 72 hours. ____Initial
I agree to adhere to all safety precautions and home skin care programs as recommended by ____Initial
The nature and purpose of the treatment has been explained to me, and any questions I have regarding this procedure have been explained to my satisfaction. ____Initial
I am over 18 years of age or I have parental consent co-signed below. ____Initial
I will call to inform my Aesthetician of any complications or concerns I may have as soon as ____Initial
My signature acknowledges that I have read the above and agree to the terms: ___________________________________________________________________________ CLIENT/PATIENT SIGNATURE ___________________________________________________________________________ PARENTAL SIGNATURE ___________________________________________________________________________ WITNESS

Source: http://skinbioaesthetics.com/biochempeelconsent.pdf

Microsoft word - res 2013.doc

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