Chemical Peel Consent Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Chemical Peel DisclaimerAfter your treatment, the skin may temporarily be red and feel tight and warm as if you got a sunburn. Slight redness and swelling may appear with deeper treatment levels. Your fresh newly exposed skin will be delicate. It is important to use a mild cleanser and keep the skin well moisturized. Use a full spectrum sunscreen 50+ SPF daily and don’t forget to reapply. Avoid the use of Retin-A, Renova for at least 7-10 days before & after. Avoid alpha or beta hydroxyl type products and all scrubs for at least 5 to 7 days before & after treatment, or until initial sensitivity subsides. Avoid swimming and the use of tanning beds for at least one week after treatment.Contraindications I understand that this procedure has contraindications which means that it is recommended not to proceed with the treatment if I have the following:Use of Accutane in the last 6 monthsDiabetesActive herpes simplex (cold sores)Facial wartsIf you form keloid or hypertrophic scarsBlood vessel diseaseIf you have a history of sun allergiesAllergic to ResorcinolPrior bad reaction to a peelInfluenzaCancer or recent radiation treatmentKidney or liver diseaseAllergies to salicylic acidsVaricella (chicken pox)Inflammation, irritation or infection of the skinIf you are now pregnant or are trying to become pregnantSurgery within the last month to the area that you plan to have peeledSunburn or significant sun exposure in the last two daysSection 2: GUEST CONSENT FORMI accept the following statements:(Required)Please check each one to agree I acknowledge that I have not used Isotretinoin (Accutane) during the last 6 months. I acknowledge that if I am prone to herpes (cold sores, fever blisters) I have consulted my physician and I am taking an antiviral to reduce the chance of a breakout. I should avoid treatments during a breakout. I acknowledge I must reveal any condition that may have a bearing on the procedure, such as pregnancy, allergies, facial waxing, medication use, diabetes, or immune deficiencies, prior to receiving treatment. I acknowledge that I should avoid the use of glycolic or retinoids for 7-10 days following the treatment. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments are required for desired results. Most guests require a number of treatments over several months with gradual results occurring after each session. I understand that proper sun protection including, but not limited to, the faithful use of broad spectrum UVA-UVB sunscreen with SPF 50 is vital to proper aftercare. I understand that compliance to my post-care instructions will greatly affect my result. I acknowledge my obligation to follow the written and spoken instructions covering my pre and post-treatment skincare regimen. I am undergoing this peel to improve my skin texture, laxity, acne breakouts, and/or skin tone. I understand I may achieve some improvement in my fine lines as well, but no guarantee has been made to me regarding my level of improvement from this peel. The Esthetician has explained to me that I may need several of these peels to achieve optimal results. I further understand that this is a superficial type of peel that normally creates mild to moderate redness with occasional areas of flaking or peeling skin. Depending on my skin, this redness may last 1-3 days. I consent to photographs being taken to evaluate treatment effectiveness. No photographs revealing my identity will be used without my written consent. Consent(Required) I agree to the notice.My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I consent to photographs being taken to evaluate treatment efficacy and for social media use. No photographs revealing my identity will be used without my written consent. I hold harmless LaVida Massage, the Esthetician, and affiliates of all circumstances that may occur during my treatment. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen and avoiding the sun/tanning booths and extreme weather conditions. If I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM: I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS. I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW. I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL. Signature(Required)PhoneThis field is for validation purposes and should be left unchanged.
