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VI Peel® Face Pre/Post Consent Form

VI Peel Chemical Peel Pre-Treatment Instructions:

    • Wait at least one-year post Accutane use before your peel.
    • One week before peel, patient should avoid: Electrolysis, Depilatory Creams, Waxing, Laser Hair Removal.
    • 3 days before peel, patient should avoid these products and/or procedures: Retin-A®, Differin®, Tazorac®, any products containing retinol, alpha-hydroxy acids or beta-hydroxy acids, or benzoyl peroxide; any exfoliating products or procedures that may be drying or irritating.
    • If you are prone to herpes simplex outbreaks, such as cold sores, consult your PCP on ways to treat prior, or discuss whether the procedure is appropriate for you.
    • If your face or treatment area has irritated skin (sunburn, open wounds, warts, sores, excessively sensitive skin) the day preceding your appointment, please contact our office before your appointment.
    • Chemical peels are contraindicated in patients with a history of recent chemotherapy or radiation therapy; allergies to salicylates like aspirin, phenol or hydroquinone, rashes or skin reactions, vitiligo, auto- immune disease (rheumatoid arthritis, psoriasis, lupus, multiple sclerosis), liver condition or any condition that may weaken their immune system; and pregnancy or breast feeding.
    • I understand if I have any acne, the peel may bring out oils and bacteria from below the surface and cause an actual breakout.

VI Peel Chemical Peel What to Expect:

    • Your provider will provide you with a fan for comfort.
    • You may experience burning, stinging, redness, heat, or tightness as the peel is administered, and over the next couple of days.

VI Peel Chemical Peel Post Instructions:

    • You will be provided with a post peel kit and specific application instructions. These are very important for the optimal outcome of your chemical peel.
    • You are encouraged to download and setup the VI Peel app, as it will provide you with reminders of what to do and when, and will supplement the written instructions provided with your post peel kit.
    • Skin may be tight and more red than usual.
    • The peel is self-neutralizing: do not wash off or apply any other products for at least 4 hours.
    • Avoid use of topical products containing AHAs, Retinoids, Vitamin A, or any type of exfoliant until the peeling process is complete.
    • Strictly avoid direct sun exposure for at least one week. Apply VI Peel SPF 50+.
    • Avoid hot water, hot tubs, saunas, steam rooms, strenuous exercise, or excessive perspiration beginning the day of the peel and throughout the entire peel.
    • 24 hours after the peel, and until peeling is complete:

    -Skin may be tight until it starts to peel.

    -Peeling will generally begin 24-72 hours after the peel has been administered, and last for 2-5 days after the skin has started peeling.

    -DO NOT PICK OR PULL THE SKIN. Allow the skin to peel at its own pace. Premature peeling of the skin may develop into post-inflammatory hyperpigmentation. You can trim the skin with small scissors.

    • Some patients may experience extreme dryness after treatment. Continued use of post care products provided and/or recommended by your provider.
    • Patients should wait until the peeling process has completed before having any other facial procedures, including facials, microdermabrasion, laser treatments, hair removal, and cosmetic injections.

Variations in amount of peeling:

The degree of peeling may vary depending on the individual’s skin type and skin conditions at the time of the peel. The success of the peel should not be determined by the amount of peeling, but by the end results that the peel will produce. Reasons why some patients experience decreased visible peeling:

    • Receiving any peel, or this specific peel, for the first time
    • Severe sun damage (increased visible peeling should develop with subsequent peels)
    • Having peels regularly with a short interval between peels
    • Frequent use of Retin-A®, alpha-hydroxy acids (AHA) or other peeling agents prior to the peel treatment
(Parent or Guardian must sign if the patient is under 18.)