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! Name * Name First First Last Last Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Email * Mobile Phone * PLEASE REVIEW AND CHECK ALL ITEMS BELOW: * I have been candid in disclosing any information that may have bearing on or be a contraindication to this treatment. If I am unsure, I will ask. If there have been changes in my skin, health, and/or medications, I have informed my practitioner prior to receiving treatment. * I have not started any new medications since my last treatment, including antibiotics, auto-immune therapies, or other photo-sensitizing drugs. If I have, I have informed my practitioner so my treatment may be adapted or re-scheduled as needed. * I understand that treatment is not an exact science. The degree of improvement varies from one person to another and depends on many variables, including but not limited to: age, skin condition, extent of skin damage, lifestyle choices, health habits, commitment to proper homecare maintenance, etc. * I am not pregnant. (Safe treatments are available during pregnancy. Please discuss these options with your practitioner if applicable.) * I have discontinued use of any form of topical prescription vitamin A (such as tretinoin) for 5-7 days prior to my scheduled appointment, or any form of professional vitamin A (such as retinol) for 3-5 days prior to my scheduled appointment. * I do not currently have active cold sores. If I am prone to cold sores or herpes-type virus, I have begin using my antiviral medication (such as Valtrex) for at least 24 hours prior to receiving treatment. * I have not taken Accutane in the past 6 months (minimum). * I have not had a chemical peel, cosmetic injections, or any other advanced treatment within 14 days prior to my scheduled appointment. * I have not waxed the area to be treated within 7 days prior to my scheduled appointment. I also agree not to wax or use depilatories on the treated area after my peel treatment until healing is completed and my skin has returned to normal (ranging from 7-14 days). * I have not tanned my skin outdoors or in a tanning bed within the past 2 weeks. I also agree to avoid tanning my skin for at least 2-4 weeks post-treatment (preferably never). This practice should be discontinued due to increased risks of treatment complications, skin cancer, and accelerated signs of skin damage and aging. * I understand that extended UV/sun exposure is prohibited while I am undergoing treatment, and the daily use of a sunscreen with a minumum of SPF 30 is required. I understand that if I choose to expose my skin in any way to direct UV/sun light, I could possibly reverse the positive effects of this treatment and other treatments, and accelerate some of the very conditions I am trying to treat. * I agree to notify my practitioner immediately with any post-treatment questions, concerns, or complications. * If I am receiving a Level 2 or Level 3 clinical peel, I agree to use the post-treatment product kit provided to me until my skin has returned to normal (usually 7-14 days), at which time I may resume the use of my normal recommended skincare regimen, and/or the application of active skincare topicals such as vitamin A creams, AHA/BHA-based products, benzoyl peroxide-based products, etc. * I understand there will be a degree of activity or sensation during this treatment. This can include sensations such as prickling, heat, etc. I understand that this sensation is temporary and will subside immediately once the treatment is completed. Any lingering warmth, tightness, skin redness, flaking, or peeling that might occur (depending on the level of treatment) is also temporary and will resolve during the post-treatment healing process. * I understand that I may not actually flake or peel from this treatment, and that peeling is considered a side effect. I also understand that flaking or peeling does not correlate with the degree of improvement. I agree not to pick or scrub any flaking or peeling skin as this could damage the new tissue forming underneath and cause scarring and/or hyperpigmentation. I agree to allow any flaking or peeling skin shed naturally. * I understand that best results in skincare are achieved over the course of several treatments. I also understand that due to the cyclical nature of skin and body processes, I will need regular skincare treatments if I wish to achieve and maintain peak results. * I understand that for best clinical peel results, 6 sessions are recommended, spaced 2-4 weeks apart (depending on the type of peel treatment). Upon completion of my program, I understand that regular facial treatments and a prescribed homecare regimen are recommended to maintain and continue improving upon my beautiful results. I understand that I may complete up to 1-2 full Skin Studio 360 peel programs per year maximum. I understand that mild, enzymatic peels may be completed more often if desired and/or necessary. * I was informed that a patch test was available to me up to 48 hours prior to receiving treatment*, even if I chose not to receive one. (*with the exception of single use peels) 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 * I do not have any of the contraindications listed above, and I am prepared to receive treatment. 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. SIGNATURE * signature keyboard Clear Date Submit If you are human, leave this field blank.