Pre and Post Chemical Peel Instructions and Informed Consent


 

Pre-Chemical Peel
Please notify us if you are taking any medications that may make your skin sensitive such as antibiotics, Retinoids, Accutane, Steroids, tranquilizers, anti viral medications, or any prescription, or over the counter medication. Please notify us of any vitamin or herbal supplements you take.
If you have a history of cold sores, please be advised you will need to be on a suppressive therapy prior to your appointment to prevent a
flare up. If you have a herpes breakout in the area being treated, your peel will need to be delayed.
You will need to purchase skincare products to prep your skin at home prior to treatment. During you initial consultation and facial your esthetician will discuss these with you, it is the clients responsibility to keep up with the homecare prep to get the correct results from the peel.

Post-Chemical Peel
Wash only with a gentle cleanser and liberally apply moisturizer. Your esthetician will discuss proper homecare with you, and products for homecare must be purchased from Old Mechanicsville Health Spa to achieve optimal results.
Do NOT vigorously rub the skin and DO NOT pick at the flaking skin as this may cause scarring.
Sun protection is critical. You should NOT have any sun exposure; wear a broad-spectrum sunscreen with a minimum of SPF 30. This
includes driving to work. Refrain from tanning for at least 2 weeks.
AVOID laser treatments, waxing, the use of depilatories, or microdermabrasion for 3 weeks.
Wait 7 days before resuming the use of Retin-A (tretinoin), Renova, Differin, Tazorac, Ziana, Veltin, Atralin, Azelaic acid glycolic acids or any other exfoliating agents.
AVOID swimming, sauna, or whirlpool use for at least 4 days after the peel.
If you were prescribed an antiviral medication by your physician, please complete the prescribed course following physicians instructions.
Chemical peels may cause swelling, redness, crusting, dryness, skin sensitivity, itching, and peeling of the site which could last for 1-2
weeks. In the days after the peel, the skin may feel and look tight, with parchment-paper like changes or darkening. These are expected
reactions and subside quickly. If you experience any adverse or reactions or reactions you are concerned about, please do not hesitate
to call.
Peeling from a chemical peel may last for several days, or several weeks, during this time you may not look your best, and may want to avoid being in public.
Peel will make skin appear sunburned for several days.
Client understands and accepts the risk that chemical peels can cause post inflammatory hyperpigmentation, especially in darker skin types. Although every precaution is taken to avoid negative side effects, client understands and accepts risk, and agrees to release provider, and Old Mechanicsville Health Spa of any liability should a negative side effect occur.
No guarantee of results has been provided to client.
Client agrees that he or she has been honest on intake form and disclosed all allergies and medications to provider. Failure on the part of the client to disclose medications, allergies, or any medical condition releases provider and Old Mechanicsville Health Spa of all liability shall injury occur.
Client agrees to keep skin dry for 48 hours post peel.
Client agrees to return for a post care facial in 6 to 8 weeks to check progress, and continue treatment plan.

I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin).

I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense.

I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.

I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these
instructions may yield undesirable results.

I understand that results are not guaranteed and for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/ environmental damage, pigmentation levels, or acne conditions.

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin therapist.

I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist.
I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any
previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.
By signing below, I verify that I have read and understand the above statements and agree to them. 

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Signature Certificate
Document name: Pre and Post Chemical Peel Instructions and Informed Consent
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Timestamp Audit
November 12, 2019 4:59 pm EDTPre and Post Chemical Peel Instructions and Informed Consent Uploaded by Brandi Bovell - intake.forms.affordable.spa@gmail.com IP 2601:5c7:4100:3d0:b4d1:af4d:ba40:3fc3