Chemical Peel Consent Form

In the field of skin care we define the process of removing excess accumulations of dead cells from the skin a peeling or exfoliation.  This can be done by using products (Glycolic acid etc.) formulated to achieve specific results know as chemical peels.

The process involves application to the skin in area with a cotton swab or small burs.  The chemical is left on the skin for a certain period of time depending on the solution, product strength, skin type, skin condition, sensitivity, age, or prior use of any exfoliating agent to obtain a specific result.

The rate of improvement depends on age, skin type, condition, degree of sun or environmental damage, pigmentation levels, as well level of peel being used.  To achieve maximum results it is recommended to do a series of treatments.

Potential Benefits
I acknowledge that no guarantee has been made about the results of the procedure.  Some areas of improvements that may be achieved are as follows:
  • Softer mother skin
  • Reduction in appearances of lines and wrinkles
  • Reduction in acne lesions
  • Reduction in appearance of sun or age spots

Potential Risk
Although it is not possible to list every potential to list every potential risk and complication, I agree, I have been informed of some possible risk, and complications which may include but are not limited to the following:
  • Swelling and redness
  • Scabbing or peeling of treated skin and surrounding areas
  • Prolonged skin sensitivity
  • Areas of increased or decreased pigmentation
  • Burning the skin
Any potential risk and complications cold result in the need to discontinue the treatment.

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