Perfect Derma Peel Consent Form
The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.
The Perfect Derma Peel is a medium depth, medical grade chemical peel suitable for all skin types. The peel contains Trichlorocacetic Acid (TCA), Retinoic Acid, Kojic Acid, Salicylic Acid, Phenol, Glutathione and Vitamin C.
• Patients who are pregnant or breast feeding
• Patients with an allergy to any peel ingredient listed above, or to aspirin
• Patients who have used Accutane within the past 4 months
• Patients who have open wounds, sunburn, infected skin, cold sores or lesions. Patients with a history of cold sores (herpes simplex) may be given an antiviral 3 days prior to the peel
• Patients who have recently had treatments such as waxing, electrolysis or chemical exfoliants
• Patients who are undergoing chemotherapy and/or radiation therapy
• Patients with a history of an autoimmune disease or any condition that may weaken the immune system
Please read the following carefully:
1. Prior to receiving treatment, I have informed my medical professional about any medications or health conditions that may contraindicate this treatment.
2. I understand that there might be some discomfort such as stinging, redness, burning, itchiness or tightness during and a week after the treatment.
3. I understand that it is important not to pull, pick at or remove peeling skin forcibly.
4. I understand that there is no specific guarantee as to the final results of the peel, and that I may require more than one treatment for optimal results.
5. I understand that while complications are extremely rare, they may occur. In the event of a reaction or complication, I agree to immediately contact my medical professional for follow up care.
6. Occasionally hyper pigmentation or hypo pigmentation may develop which can persist for weeks or months after the treatment.
7. I understand that post peel care includes use of Mineral Perfection SPF 30 or an SPF 30 or above and avoid sun exposure during the exfoliation process.
8. I understand that extended sun exposure, including use of tanning beds, is prohibited both before and after The Perfect Derma Peel treatment. Avoid sweating excessively or use of steam/sauna for 3 days post peel.
9. I understand that this is an elective procedure and is non refundable.
10. 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.