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.Your SignatureSignature of Clinician:Date signed MM slash DD slash YYYY Have you recently used Accutane, topical medications, or antibiotics? Yes No Have you recently had aesthetic fillers, injectables or laser treatments? Yes No 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.Printed Name SignatureDate Signed MM slash DD slash YYYY