PCA Skin Peel Consent

Form Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as: trentinoin, Retin‐A®, Accutane®, Differin®, Tazorac®, Avage®, EpiDuoTM, or Ziana®.

I understand there may be some degree of discomfort such as stinging, pin‐prickling sensation, heat or tightness.

I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc.

I understand I may or may not actually peel and that each case is individual. I understand that the amount of peeling does not correlate with degree of improvement.

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximum results, I may need several treatments.

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the physician/clinician who performed the treatment. I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment and during the 14 days, prior to and following the end of treatment (we recommend that this practice be discontinued altogether).

I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum of SPF 30 is mandatory.

I have not had any other chemical peel of any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location.

I understand that I should follow my clinician’s recommendations for post‐procedure skin care to minimize side effects and maximize results. I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post‐peel care instructions as I am directed.
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Have you recently used Accutane, topical medications, or antibiotics?
Have you recently had aesthetic fillers, injectables or laser treatments?
I acknowledge the following:
  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take‐home regimen in the treated areas for minimum 2 weeks preand post‐treatment.
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion, or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Skin Retreat.
  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. This consent form Is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.
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