Open
Doctor's Search
Search Team Members by name and also by section
Search
Call us now!
248-426-7200
Modern Medicine; Old Fashioned Care
Toggle menu
Skip to content
PrimeCare of Michigan
>
Chemical Peel Consent
Chemical Peel Consent
Chemical Peel Consent
Name
First
Last
Date
MM slash DD slash YYYY
Email
Consent
I acknowledge the following
The VI Peel contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel
will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation
(including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne
scars; and stimulate the production of collagen, for firmer, more youthful skin.
Contraindications:
• Patients who are pregnant or who are breastfeeding
• Patients who have an aspirin, hydroquinone, or phenol allergy
• Patients who have used oral isotretinoin (Accutane) within the past 6 months
• Patients who have active cold sores, warts, open wounds, or history of herpes simplex
• Patients who are undergoing chemotherapy and or radiation therapy within 6 months
• Patients with a history of an autoimmune (i.e. Lupus) or liver disease/disorder, as well as, any
condition that may weaken their immune system
I acknowledge
(Required)
Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.
I acknowledge
(Required)
I understand that there may be some degree of discomfort such as burning, stinging, redness, heat, or tightness during and a week after the procedure.
I acknowledge
(Required)
I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.
I acknowledge
(Required)
I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.
I acknowledge
(Required)
I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.
I acknowledge
(Required)
I understand that maintenance of VI Peel® treatments are necessary to maintain results as well as the recommended VI Derm® skin care regimen and SPF 50+.
I acknowledge
(Required)
I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®.
I acknowledge
(Required)
I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub, steam room, and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)
I acknowledge
(Required)
I understand that I must protect my skin with VI Derm® SPF 50+ and avoid sun exposure during the 7 day exfoliation process.
I acknowledge
(Required)
I understand that this is an elective cosmetic procedure.
I acknowledge
(Required)
I understand that no other chemical peels, facial machine brushes, or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so.
The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
Signature
Search
+
