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CLINICAL PEEL - Consent

CLINICAL PEEL

Consent to Treat

Welcome to SIMPLY DAWN! We are excited for your clinical peel service today. You have previously signed a Clinical Peel Reminders & Contraindications form which gives a comprehensive list of pre-treatment reminders, contraindications, and post-treatment information regarding your clinical peel service. Please read and check each item below, signifying that you have complied with all pre-treatment reminders and are prepared to receive your clinical peel treatment today. If you have any questions, please ask your practitioner prior to the start of your service. Thank you!

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PLEASE REVIEW AND CHECK ALL ITEMS BELOW: *
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CONTRAINDICATIONS

Clinical peel treatments are a safe and effective way to improve the tone and function of the skin. There are a few contraindications for receiving peel treatments, however. Please review this list to ensure you are free from conditions that would prevent you from receiving treatment, and contact us if you have any questions prior to your scheduled appointment.

Precautions and Conditional Contraindications:

  • Allergy to aspirin (will prevent use of certain peels)

  • History of cold sores or fever blisters (must use an anti-viral medication such as Valtrex starting 24 hours prior to treatment)

  • Pregnant or lactating (will prevent use of certain peels)

  • Outdoor lifestyle (will discuss safe treatment options)

  • Rosacea (will prevent use of certain peels)

  • Facial waxing (must wait 1 week prior to treatment)

  • Laser hair removal (must wait 2 weeks prior to peel treatment)

  • Use of prescription keratolytics or Vitamin A topicals (discontinue 5-7 days prior to treatment)

  • Use of professional retinol-based products (discontinue use 3-5 days prior to treatment)

  • Botox or dermal fillers (must wait 2 weeks prior to treatment)

  • Sunburned, wind-burned, or compromised skin (must wait 2 weeks prior to treatment)

  • Use of antibiotics (may increase skin sensitivity; will discuss treatment options case-by-case)

Absolute Contraindications:

  • Use of Accutane (must be off for 6-12 months prior to treatment)

  • Current use of hydrocortisone on treatment area

  • Visible redness, irritation, or inflammation

  • Active cold sores or facial rash

  • Active rosacea flare-ups

  • Abnormal lesions

  • Current treatment for serious medical condition (doctor’s note required)

  • Autoimmune disease (doctor’s note required)

  • Medications for diabetes, Lupus, or chemotherapy treatments

  • History of keloids or hypertrophic scarring

  • Frequent use of tanning beds or frequent sun exposure

  • Any infectious disease

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CONSENT TO TREAT

By signing below, I acknowledge that all clinical peel and pre-treatment reminders, contraindications, and post-treatment guidelines have been provided to me in full, and I have reviewed them prior to receiving treatment. A list of contraindications has also been provided to me above. I understand the DO’s and DON’T’s for receiving a Clinical Peel, and I have abided by all guidelines prior to receiving treatment. If something was unclear to me, I have consulted with my practitioner, and my question/s have been answered. For my safety, I have informed my practitioner of any contraindications that may be present, or of changes in my skin, overall health, or medications prior to receiving treatment. I understand that I may experience post-treatment skin dryness, skin flaking, skin peeling, or skin shedding for 3-14 days post peel. I also understand that though rare, I may experience a histamine reaction resulting in temporary edema (skin puffiness). I understand that a patch test was made available to me up to 48-hours prior to receiving treatment, even if I have chosen not to receive one. If I am under a doctor’s care for any medical condition, I understand that I should consult with my doctor prior to receiving treatment. If I choose to receive a clinical peel without my doctor’s approval, I am assuming full responsibility and hereby and forever release SIMPLY DAWN [Skin Spa | Wellness Studio] from any and all liability. I acknowledge that my practitioner may use before and after pictures for business purposes, and that I may request to have my identity masked. I give my permission and consent to receive treatment. I am either of lawful age and I am signing for myself, or I am providing a parent/guardian signature and I give my consent for my legal minor to receive treatment.

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8821 S Redwood Rd, Ste B
West Jordan, UT 84088
801-675-4075 (call/text)
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