IMAGE Peels Form

Name

Last Name

This form is designed to give you the information needed to make an informed decision about your cosmetic treatment.

If you have any questions before your session, it is highly recommended that you ask your doctor.

The treatment was explained to me in detail. The treatment was explained to me in detail. Agree Disagree

The benefits of what I can realistically expect to see from my Clinical Peel have been fully explained to me. The benefits of what I can realistically expect to see from my Clinical Peel have been fully explained to me. Agree Disagree

TREATMENT (Please select one)

Check Boxes (Please Read Carefully) Check Boxes (Please Read Carefully) I AM NOT PREGNANT.** I AM NOT ALLERGIC TO ASPIRIN I HAVE NOT USED GLYCOLIC ACID FOR 24 HRS. I HAVE NOT USED RETINOL PRODUCTS FOR 72 HRS. I HAVE NOT TAKEN ACCUTANE IN THE PAST YEAR. I AGREE NOT TO PICK, PEEL, OR SCRATCH THE SKIN DURING HEALING PHASE I AGREE THERE MAY BE CRUSTING AND SHEDDING OF SKIN. I AGREE THAT I CURRENTLY DO NOT USE HYDROCORTISONE I DO NOT HAVE ACTIVE COLD SORES I HAVE NOT RECEIVED RADIATION TREATMENTS. I AGREE IT IS MANDATORY TO USE IMAGE POST PEEL KIT I AGREE TO AVOID DIRECT SUN EXPOSURE FOR 2 WEEKS. I AGREE TO NOTIFY DR/AESTHETICIAN OF ANY CONCERNS. I AGREE TO APPLY SUNBLOCK DAILY I AGREE NOT TO WAX FOR 7 DAYS PRE/POST-TREATMENTS I AGREE TO FOLLOW UP WITH SCHEDULED APPOINTMENT. I AGREE NOT TO USE RETIN-A PRODUCTS 7 DAYS PRE/POST- TREATMENTS

CONSENT CONSENT I hereby give my consent and authorization voluntarily and release Skin Ego from any claims, implied or stated that, I have or may have in the future with this treatment, regardless of result. I am stating that the treatment and precautions above have been explained to me in detail and that I fully understand.

I understand that submitting this form is a confirmation of my agreement to all statements contained within

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IMAGE Peels Form

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