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Chemical Peel Treatment Consent Form

GLYTONE PEEL

VITALIZE PEEL

REJUVENIZE PEEL

PURPOSE: Chemical 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

ONE WEEK BEFORE YOUR CHEMICAL 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 chemical peel

TWO TO THREE DAYS BEFORE YOUR CHEMICAL 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
  • 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 chemical peel

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 CHEMICAL PEEL:

It is common and expected that your skin will be red, 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 chemical peel: skin breakout or acne, rash, swelling, and burning.

Call the office immediately (781-762-2800) if you have any unexpected problems after the procedure. If we are closed, contact your PCP.

Although most people experience peeling of their facial skin, not every patient notices that their skin peels after a chemical peel procedure.

Lack of peeling is NOT an indication that the peel was unsuccessful. If you do not notice actual peeling, please know that you are still receiving all the benefits of the chemical peel, such as stimulation of collagen production, improvement of skin tone and texture, and diminishment of fine lines and pigmentation.

There are a number of reasons why a patient may not have peeling or may experience minimum peeling. The reasons may include:

  • Having peels regularly with a short interval between peels
  • Frequent use of Retin-A, AHA, or other peeling agents prior to the chemical peel treatment
  • Severe sun damage

Please read and initial the following:

(Parent or Guardian must sign if the patient is under 18.)