Name *

First Name

Last Name

Terms & Conditions *

Please follow the instructions and guidelines provided by your Skin Specialist/ Nurse or Physician contained in your Starter Kit.

I understand that if, for any reason, I stop or interrupt the prep procedure I must contact my Skin Specialist immediately and notify them of any changes to my skin care regime. My appointment or type of peel may need to be changed or rescheduled

I understand that a test patch must be done prior to treatment for Salicylic Acid and selected Vitamin A peels or where there is the possibility of an allergy

I will notify my Skin Specialist immediately if there is any change to my health, including the introduction of any new medications (topical or oral) or oral supplements as they may cause increased sensitivity to my peeling treatment

I agree to STOP, DISCONTINUE or NOT HAVE ANY OF THE FOLLOWING TREATMENTS: *

1 week prior to treatment: Anti-wrinkle injections, Prescription topical Retin A, Home Needling

2 weeks prior to treatment: Waxing, bleaching or hair dying any areas to be treated; Depilatory use in any treated area; Electrolysis on any treatment area; IPL/Laser Hair removal treatments; IPL/Laser Skin Rejuvenation (Only prior to very superficial peels); Sun exposure to area to be treated; Facial treatments of any kind including any AHA, BHA or Vitamin A treatments; Microdermabrasion / Epidermal Levelling; Dermal Fillers

4 weeks prior to treatment: IPL/Laser Skin Rejuvenation (Only prior to Superficial to Medium Depth peels); AHA, BHA, Vitamin A or TCA Superficial to Medium Depth Peels; In clinic Needling

3-6 months prior to treatment: Medical Needling; Fractional Ablative Laser Resurfacing; TCA or Phenol Deep Peeling; Facelift Surgery

6-12 months prior to treatment: Roaccutaine; Full Ablative Laser Resurfacing

I consent that: *

I have completed the client medical form accurately.

I currently have no cold sores and if I have the Herpes Virus I will prep on an antiviral.

I am not currently pregnant or breastfeeding.

I have no allergies that will contraindicate me to having the treatment. Eg Salicylic acid

I do not have open lesions, eczema or inflamed skin on the area to be treated.

I understand that there are no guaranteed results from this treatment. Many variables exist such as age, sun damage, ongoing sun exposure, smoking, excessive alcohol intake, climate, diet and water intake, skin thickness and sensitivity.

I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin which may or may not result in skin peeling or flaking as each case is individual.

I will not scratch, pick, pull at or abrade the treated skin.

I understand that direct sun exposure and use of a tanning booth is prohibited during this treatment time, and that a minimum SPF 15 physical sun protection (no fragrance) must be applied daily.

I understand that to achieve maximum results and to avoid complications the recommended home care routine must be followed. I understand that if I alter the routine or use products not recommended by the skin care professional the results could be altered or inhibitive.

I understand that it may take several treatments to obtain the desired results.

I understand that the following side effects can occur: 1. Redness and swelling 2. Itching or irritation 3. Skin peeling or flaking up to 14 days after the procedure 4. Hyperpigmentation 5. Acne Breakouts

I understand the following complications can occur, although are very rare. I also understand that if they are to occur I accept sole responsibility for any medical care that may become necessary. I will immediately contact the Doctor, Nurse or Skin Specialist performing the treatment. 1. Hypopigmentation 2. Infection 3. Scarring

I understand the goals of the treatment as well as the limitations and possible complications.

My Skin Specialist has provided the information and has answered all my questions concerning this procedure. I clearly understand the above information

In order to achieve the best results from your peel treatment we ask that you read and understand the following instructions. Your Skin Specialist/Physician will review the relevant post-treatment protocol with you. *

Your recovery time will be influenced by the type of peel treatment you have received and your individual skin’s response. Your Skin Specialist will have discussed with you the individual time frame you should expect.

I agree to STOP, DISCONTINUE or NOT HAVE ANY OF THE FOLLOWING TREATMENTS: *

For 24 hours post treatment: Exercise (avoid getting overheated), Bathing or Showering

For 5-10 days post treatment: Exfoliating products (scrubs, AHA’s, BHA’s, Vitamin A); Products not recommended by my Skin Specialist; Home Needling; Anti-wrinkle injections; Prescription topical Retin A; Sun exposure to area treated

2 weeks post treatment: Waxing, bleaching or hair dying any areas to be treated; Depilatory use in any treated area; Electrolysis on any treatment area; IPL/Laser Hair removal treatments; IPL/Laser Skin Rejuvenation (Only prior to very superficial peels); Facial Treatments of any kind including any AHA, BHA, Vitamin A or TCA treatments; Microdermabrasion / Epidermal Levelling; Dermal Fillers

4 weeks post treatment: IPL/Laser Skin Rejuvenation (Only prior to Superficial to Medium Depth peels); AHA, BHA, Vitamin A or TCA Superficial to Deep Peels; Needling (Standard In clinic or Medical); Fractional Ablative Laser Resurfacing / Full Ablative Laser Resurfacing; Facelift Surgery

I also agree to:- *

Not to pick at skin

Increase water intake to include “at least” 8 glasses

Wear Physical Sun Protection and reapply every 2 hours

Not use wash cloths, or any other type of cloth on skin, instead, apply cleanser to clean hands and foam for application.

Adhere to the following Aftercare Instructions: For 5 days post treatment please use the following products - Gentle Cleanse, Hydrating Serum, Redless Serum or Posttreatment Balm

*

I understand and agree to comply with the above instructions. I also agree to contact the clinic with any further questions.