Advanced Services Consent Form For Chemical Peel, Microdermabrasion and Microcurrent clients: The treatment you will receive is a clinical treatment designed to exfoliate or remove the outer layers of skin. We cannot guarantee precise results, peeling times, or level of discomfort. Your skin is unique to you! During the treatment, you may experience some temporary stinging, discomfort, or flushing of the skin. You may experience prolonged redness, irritation, dryness, or in rare instances, severe allergic reaction, scabbing, infection, eye injury, or scarring. For most peel clients, shedding of skin begins within 48 hours and usually subsides within 5‐7 days. Your participation in your skin care helps determine the outcome. It is important that you follow the home care regimen, products, and timeline your esthetician has recommended. Skin Retreat offers the IMAGE Post Peel Treatment Kit, which contains all necessary products. Essential aftercare includes gentle manual cleansing of skin using a mild cleanser, application of moisturizer morning, night, and whenever skin feels tight or dry, and reapplication of SPF 30 or greater sunscreen throughout the day, as well as the professional advice of your esthetician, throughout the healing process. Avoid makeup on the day of your peel. Keep skin cool, with no heat/hot water applied to the face and avoid strenuous exercise. To receive Skin Retreat Advanced Services please initial as appropriate: I have not used glycolic(s) for 24 hours. I have not used Retin‐A for 72 hours. I have not had a Botox or collagen injection for 72 hrs. I have not taken Accutane in the past year. I do not have active cold sores. I have not received radiation treatments. I am not allergic to aspirin. I understand there may be crusting & shedding of skin following peels. I agree not to pick, peel, or scratch healing skin. I agree to reapply sunscreen throughout the day. I agree not to wax for 7 days pre/post treatment. To receive Skin Retreat Advanced Services please initial as appropriate: I agree to avoid direct sun exposure for 2 weeks. I agree not to tan for 30 days pre/post peel. A peel patch test has been/will be given to me. I do not have epilepsy or multiple sclerosis. I am not currently using a pacemaker or defibrillator. I have no heart, muscular, or circulatory problems. I do not have any metal implants, or a metal IUD. I agree to notify my esthetician of any concerns. I agree to follow the home care product advice given by my esthetician. I am not pregnant. (If pregnant, please discuss treatment options with your esthetician.) If I am under the supervision of a physician I have discussed the treatment plan with him/her. The treatment was explained to me in detail. Acknowledgement The treatment procedure and benefits of what I can realistically treatment(s) have been fully explained to me. If you were unable to initial any of the above conditions, please explain.HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration, and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little‐to‐no downtime. The treatment is soothing, moisturizing, non‐invasive and generally non‐irritating. As with most procedures, visible results from HydraFacial will vary from person to person. What to expect: Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity. You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. • Client experiences may vary. Some clients may experience a delayed onset of these symptoms. You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results. The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen. Active acne or infection? Yes No Open lesion or cold sore? Yes No An active infection in the treatment area? Yes No Active sunburn? Yes No Skin conditions such as eczema, dermatitis, or rashes? Yes No An autoimmune disease such as lupus? Yes No A viral concern such as HIV or hepatitis? Yes No Anticoagulants Therapy? Yes No Melanoma or lesions suspected of malignancy? Yes No Pregnancy or lactation? Yes No Neurological disorders such as epilepsy (LED Lights)? Yes No Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)? Yes No Hyperthyroidism(Lymphaticdrainage)? Yes No Crohn’s Disease (Lymphatic drainage)? Yes No Deep Venous Thrombosis (Lymphatic drainage)? Yes No Printed Name Your SignatureDate Signed MM slash DD slash YYYY Esthetician’s SignatureDate Signed MM slash DD slash YYYY
