Chemical Peel Informed Consent
The information provided in this informed consent should be followed by all patients receiving a Chemical Peel treatment. You will be asked to sign this form acknowledging that you have read and understood all of the information presented.
PATIENTS WHO SHOULD NOT BE TREATED:
Patients with active cold sores or warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated. Inform the esthetician if you have any history of herpes simplex. You should also not have a chemical peel treatment if you have a history of allergies, rashes, or other skin reactions, or may be sensitive to any of the components of this treatment. Most peels should not be performed on patients with an allergy to salicylates (i.e., aspirin). This peel is also not recommended if you have taken Accutane within the past year, or received chemotherapy or radiation therapy and should not be administered to pregnant or breastfeeding (lactating) women.
ONE WEEK BEFORE YOUR PEEL:
Avoid these products and/or procedures for one entire week prior to your chemical peel:
Laser Hair Removal
Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol
TWO TO THREE DAYS BEFORE YOUR PEEL:
Any products containing AHA or BHA, or benzyl peroxide Any exfoliating products that may be drying or irritating
AFTER YOUR PEEL:
It is crucial to the health of your skin and the success of your peel that these guidelines be followed:
If Retinoic Acid is used as part of your treatment, your skin will have a light yellow tinge immediately after the procedure. This is temporary and will fade in 1 to 2 hours. It is recommended to wait until the evening to wash your face, however if you should choose to wash it sooner, please wait until after the yellow tinge completely disappears (1-2 hours).
It is imperative that you use a sunscreen with an SPF of at least 20 and avoid direct sunlight for at least 1 week.
Patients with hypersensitivity to the sun should take extra precautions to guard against exposure immediately following the procedure as they may be more sensitive following the peel.
Your skin may be more red than usual for 2-3 days. Please avoid strenuous exercise during this time.
Approximately 48 hours after the treatment, your skin will start to peel. This peeling will generally last 2 to 5 days. DO NOT PICK OR PULL THE SKIN.
When washing your face, do not scrub. Use a gentle cleanser.
Apply a light moisturizer as often as needed to relieve dryness and tightness.
Do not have any other facial treatments for a least one week after your
You may resume the regular use of Retin-A, alpha-hydroxy acid (AHA), or bleaching creams only after the peeling process is complete.
ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR PEEL:
It is common and expected that your skin will be red and possibly itchy and/or irritated. It is also possible that other adverse experiences (side effects) may occur. Although rare, the following adverse experiences have been reported by patients after having a Chemical Peel: skin breakout or acne, rash, dark spots, swelling, and burning.
Call the office immediately if you have any unexpected problems after the procedure.
LACK OF EFFECT:
Although most people experience peeling of their facial skin, not every patient notices visibly peeling after a Chemical Peel procedure. Lack of peeling is NOT an indication that the peel was unsuccessful. If you do not notice actual peeling, please know that you are still receiving all the benefits of the peel, such as: stimulation of collagen production, improvement of skin tone and texture, and diminishment of fine lines and pigmentation.
There are a number of reasons why a patient may not have peeling or may experience minimum peeling. The reasons may include:
Having peels regularly with a short interval between peels.
Frequent use of Retin-A, AHA, or other peeling agents prior to the Peel treatment.
Severe sun damage.
Proper skin evaluation by your skin care professional prior to your peel is important and will help predict the outcome of your peel.
I understand that the Peel treatment is not an exact science and the degree of improvement is variable. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results will vary per patient. No refund will be given.
I understand that occasionally there is no visible improvement and another form of treatment may be required.
I do not have any of the conditions described in the “Patients Who Should Not Be Treated” section.
I understand that any rescheduling must be done 72 working hours before my treatment.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
I release Mari Van Schalkwyk and all medical staff, from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.