'The Perfect Derma Peel' Consent

THE PERFECT DERMA PEEL

Consent to Treat

Welcome to SIMPLY DAWN! We are excited for your Perfect Derma Peel service today. You have previously signed a Perfect Derma 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:

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've informed my practitioner so my treatment may be adapted, if 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 and nutrition 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 7 days prior to my scheduled appointment, or any form of professional vitamin A (such as retinol) for 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 3 days prior to receiving treatment.

I have not taken Accutane within the past 4 months (minimum).

I have not had a chemical peel, cosmetic injections, or any other advanced treatment within 2-4 weeks prior to my scheduled appointment.

I have not waxed the area to be treated within 7-10 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 (at least 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 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.

Although extremely rare, I agree to contact SIMPLY DAWN immediately for followup care in the event of a reaction or complication. I will also reach out if I have any questions or concerns.

I agree to use the post-treatment product kit and follow the post-healing instructions that have been 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. This includes the application of active skincare topicals such as retinoids, AHA/BHA-based, benzoyl peroxide-based, and/or exfoliating products.

I understand there will be a degree of activity or sensation during this treatment. This can include sensations such as prickling, stinging, itchiness, tightness, and heat. I understand that these sensations are temporary and will subside once the treatment is completed and my skin has fully healed. Any lingering warmth, tightness, skin redness, itchiness, peeling, or flaking that might occur is also temporary and will resolve during the post-treatment healing process.

I understand that I may not peel or flake intensively from this treatment, and that peeling is considered a side effect. I also understand that peeling and/or flaking 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 peeling or flaking skin to shed naturally. If I do peel in larger "sheets," I will either trim these pieces with small nail scissors or allow them to 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, and I will need to consistently use my prescribed homecare regimen if I wish to achieve and maintain peak results.

I understand that best results are obtained through a series of up to 4 Perfect Derma Peel treatments, spaced 4 weeks apart. 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.

I was informed that a patch test for hydroquinone and/or hydrocortisone was available to me up to 48 hours prior to receiving treatment, even if I chose not to receive one. Hydroquinone is contained in the Plus Plus Booster, as well as the B Cream topical. Hydrocortisone is contained in the Plus Plus Booster, Clear Booster, and Post Peel Moisturizer.

I understand that no other chemical peels or medical device treatments are to be performed on my skin until my medical professional releases me to do so.

CONTRAINDICATIONS

The Perfect Derma Peel is a highly advanced medium-depth peel, and is a safe and effective way to improve the tone and function of the skin. There are a few contraindications for receiving The Perfect Derma Peel, 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:

History of cold sores or fever blisters (must use an anti-viral medication such as Valtrex starting 3 days prior to treatment)
Use of antibiotics (may increase skin sensitivity; will discuss treatment options case-by-case)
Prior chemical peel (must wait 4 weeks prior to treatment)
Laser treatment on or around the area to be treated (must wait 4 weeks prior to peel treatment)
Botox or dermal fillers (must wait 2 weeks prior to treatment)
Outdoor lifestyle (will discuss safe treatment options)
Rosacea

Absolute Contraindications:

Sunburned or wind-burned skin, open wounds, facial rash, abnormal lesions, skin infection, active cold sores, or compromised skin (must wait at least 2 weeks prior to treatment, or longer until skin has completely healed)
Pregnant or breastfeeding
Use of Accutane within the past 4 months
Allergy to aspirin
Allergy to any ingredient found in the peel solution, including trochloroacetic acid (TCA), retinoic acid, kojic acid, salicylic acid, phenol, glutathione, and vitamin C.
Allergy to additional ingredients found in the Plus Plus Booster, including hydroquinone and hydrocortisone.
Allergy to additional ingredients found in the Clear Booster, including benzoyl peroxide and hydrocortisone.
Current use of hydrocortisone on treatment area
Visible redness, irritation, or inflammation
Active rosacea flare-up
Current treatment for serious medical condition (doctor’s note required)
History of autoimmune disease or any condition that may weaken the immune system (doctor's noted required)
Medications for diabetes, Lupus
Chemotherapy treatment and/or radiation therapy
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 Perfect Derma 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 peeling, skin flaking, or skin shedding for 7-14 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 for hydroquinone and/or hydrocortisone 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 Perfect Derma 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 understand that 1) before and after photos may be taken to document treatment results and/or processes, 2) these photos may be used by SIMPLY DAWN for business and/or marketing purposes, and 3) I may request to have my identity masked prior to posting publicly. I am either of lawful age and I am signing for myself, or I am a legal parent/guardian and I give my consent for my minor to receive treatment.

SIGNATURE

Clear

PARENT/GUARDIAN SIGNATURE (if patient is a minor)

Clear

Date

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