Fillable Consent Form For Epidermal Peels printable pdf download

PREMIER DERMATOLOGY

PATRICK KEEHAN, D.O.

508 S. Adams Street, Suite 100

Telephone 817-769-3603

Fort Worth, Texas 76104

Fax 817-348-0113

CONSENT FORM FOR EPIDERMAL PEELS

(SALICYLIC ACID OR GLYCORIC ACID)

Our superficial peels usually result in little to no downtime. Our professional strength acids are performed as part of a

corrective treatment designed to give the skin the maximum exfoliation with minimum irritation.

What can I expect to feel during the acid application?

A stinging or burning sensation is felt by most individuals, however, depending on your skin’s own sensitivity level, you

may experience very little to no sensation at all. You do not have to experience a “sensation” to obtain results.

What can I expect in the days following my treatment?

Side effects vary among individuals. Some clients will have no visible side effects; peels can lighten, tighten, and

brighten skin even if the client does not experience any peeling. Other clients may experience tightness, mild flaking and

temporary dryness, mild redness, small blisters and mild scabbing. You are not to pick skin if it begins to flake or peel as

this could cause trauma to the skin, resulting in hyperpigmentation or scarring.

What difference can I expect to see in my skin?

Although no guarantee is made as to the outcome, most people feel the skin is much smoother after the first treatment.

With subsequent treatments, in combination with the recommended homecare, it is not uncommon to see dark spots fade,

fine lines become minimized, fewer blackheads, oil production can seem lighter and breakouts fewer. Usually, a series of

peels are recommended, followed by monthly maintenance peels.

Because there are potential side effects, my signature below indicates that I have read the above, and that I understand

and certify that each of the following statements are true:

1. I am not currently pregnant, or lactating.

2. I am not currently, nor have I used Retin-A (or any tretinoin product) on my face, neck or chest in the past four

weeks.

3. I am not currently, nor have I taken Accutane, Prednisone, (or any type of steroid) in the past six weeks.

4. I am allergic to: ____________________________________________________________________________

5. I have discussed any hormonal changes or supplements with my skin care professional.

6. I am not currently, nor have I used Benzoyl Peroxide in the past three days.

7. I have not waxed area to be treated in the past 48 hours, nor will I within 14 days of this treatment.

8. I have not shaved area to be treated in the past eight hours.

9. I have not used a tanning booth or laid out in the sun in the past week and I agree to refrain from tanning booths

and sun bathing for 21 days following this treatment.

10. I have not had a chemical peel or dermabrasion procedure in the past 30 days.

11. I have not had, nor will I have any other kind of exfoliation treatment within 14 days of this treatment.

Consent Form For Epidermal Peels