Rejuvinize Consent Form Chemical Peels Vitalize Peel Rejuvinize Peel PURPOSE: The SkinMedica Peels range from very superficial to superficial, designed to improve the texture and appearance of your skin. 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 • Patients with a history of allergies (especially allergies to salicylates like aspirin), rashes, or other skin reactions, or those who may be sensitive to any of the components in this treatment • Patients who have taken Accutane® within the past year • Patients who are pregnant or breastfeeding (lactating) • Patients who have received chemotherapy or radiation therapy • Patients with vitiligo • Patients with a history of an autoimmune disease (such as rheumatoid arthritis, psoriasis, lupus, multiple sclerosis, etc.) or any condition that may weaken their immune system. Note: Patients who have had medical cosmetic facial treatments or procedures (e.g. laser therapy, surgical procedures, cosmetic filler, microdermabrasion, etc) should wait until skin sensitivity completely resolves before receiving a SkinMedica Peel. ONE WEEK BEFORE YOUR SKINMEDICA PEEL AVOID THESE PRODUCTS AND/OR PROCEDURES*: • Electrolysis • Waxing • Depilatory Creams • Laser Hair Removal • Patients who have had BOTOX® injections should wait until full effect of their treatment is seen before receiving a SkinMedica Peel THREE DAYS BEFORE YOUR SKINMEDICA PEEL AVOID THESE PRODUCTS AND/OR PROCEDURES*: • Retin-A®, Renova®, Differin®, Tazorac® • Any products containing retinol, alpha-hydroxy acid (AHA) or beta-hydroxy acid (BHA), or benzoyl peroxide • Any exfoliating products that may be drying or irritating *Note: The use of these products/treatments prior to your peel may increase skin sensitivity and cause a stronger reaction. ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR SKINMEDICA PEEL: It is common and expected that your skin will be red, dry, 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 SkinMedica Peel: skin breakout or acne, rash, swelling, and burning. Call the office immediately if you have any unexpected problems after the procedure. VARIATIONS IN AMOUNT OF PEELING FOR VITALIZE PEEL/REJUVENIZE PEEL ONLY: The degree of peeling may vary from mild flaking to skin peeling in sheets depending on the individual’s skin type and skin condition at the time of the peel. Reasons why some patients experience decreased visible peeling: • Receiving Vitalize Peel/Rejuvenize Peel for the first time • Severe sun damage (increased visible peeling should develop with subsequent peels) • Having peels regularly with a short interval between peels • Frequent use of Retin-A, alpha-hydroxy acids (AHA) or other peeling agents prior to the peel treatment Regardless of the degree of peeling, the skin is still sloughing off at an accelerated rate, which will result in the improvement of skin tone, texture, and diminishment of fine lines and pigmentation. PLEASE READ AND CHECK THE FOLLOWING:* I do not have any of the conditions described in the “Patients Who Should Not Be Treated” section. I understand that the actual degree of improvement cannot be predicted or guaranteed. I understand that the amount of visible peeling cannot be predicted or guaranteed. I understand that I may need several of these peels to achieve optimal results. I understand that for optimum results the post-peel instructions must be followed utilizing skin care products recommended by your physician or aesthetician. Patient Name* Date* MM slash DD slash YYYY Untitled* I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure. Staff signature ___________________ Patient signature ___________________ CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.