Chemical Peel Waiver – Aesthetically Yours By Mel

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Aesthetically Yours By Mel

Advanced Exfoliations & acid treatments

Consent

Informed Consent for Advance Exfoliations and Acid treatments

I have been given the Skin History Questionnaire and have read and answered the questions thoroughly. *

Yes
No

I have discussed any further questions that I may have with my skin care therapist. *

Yes
No

My skin care therapist has answered any questions I have regarding my aftercare. -I acknowledge my obligations to closely follow the after care instructions and visit my skin care therapist to a post peel treatment as specified. *

Yes
No

I am aware and acknowledge that there is a rare possibility of an allergic reaction. *

Yes
No

I have discussed with my skin care therapist about any such reactions and understand them. *

Yes
No

I have been advised that my treatment in a non invasive, light epidermal exfoliation consisting of any of the following : Salicylic, Glycolic, Lactic, Azelaic or Mandelic Acids. *

Yes
No

The use of the above ingredients stimulates the skin to produce new skin cells and new collagen formation, increases blood flow to the skin and if appropriate decongests acne is skin. It does not replace deep chemical peels, laser resurfacing or plastic surgery. *

I acknowledge
I do not acknowledge

I acknowledge that during the application I will notice a warm sensation and the skin may tingle, sting or burn. Immediately after the peel the skin may appear red and by day two may feel tighter, and be more sensitive. Day two through seven, the skin may peel. *

I acknowledge
I do not acknowledge

I am not to pick or peel the old skin. Picking or pulling may lead to infection. I may experience some small breakouts after the treatment. *

I acknowledge
I do not acknowledge

I acknowledge that I will avoid direct sun exposure during this procedure and will apply a sunscreen daily. *

I acknowledge
I do not acknowledge

I acknowledge that there is NO GUARANTEE that dark discolouration on the skin, known as Melasma will be reduced or faded. *

I acknowledge
I do not acknowledge

I acknowledge that I have not been using Retin A or Renova for the past two weeks. *

I acknowledge
I do not acknowledge

I acknowledge that I have not been on accutaine during the past six months. *

I acknowledge
I do not acknowledge

I acknowledge that if I am prone to cold sores, the treatment could possibly cause a flare up. *

I acknowledge
I do not acknowledge

I acknowledge that I am not aspirin sensitive, or if I am I have discussed this why my skin therapist and understand there could be a reaction. *

I acknowledge
I do not acknowledge

Name (Electronic signature) *

First

Last