1. Allergic to aspirin or any salicylic sensitivity
2. Allergic to citric fruits (oranges, grapefruit, lemons)
3. History of being “highly allergic” to anything
4. Pregnant or lactating
5. Currently use of antibiotics (topical or systemic)
6. Use of Accutane within the past 12-months
7. Laser resurfacing surgery within the last 12-weeks
8. Using glycolic acid products
9. Use of Retin-A, Renova, retinoids (Vitamin A) in the last 4-weeks
10. Broken Skin on areas to be treated
11. Visible inflammation or inflammatory lesions
12. Recent peels within eight weeks
13. Herpes virus (cold sores)on mouth
14. Laser Hair Removal within 6 weeks
15. Currently undergoing chemotherapy or radiation treatments

In the event of any questions or concerns, I will consult my skin care professional
immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I will hold the skin care professional and staff harmless from any liability that may result from this treatment.
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.