{"id":1046,"date":"2024-03-05T01:09:14","date_gmt":"2024-03-05T01:09:14","guid":{"rendered":"https:\/\/skinretreattx.com\/?page_id=1046"},"modified":"2024-03-05T01:09:14","modified_gmt":"2024-03-05T01:09:14","slug":"pca-skin-peel-consent","status":"publish","type":"page","link":"https:\/\/skinretreattx.com\/pca-skin-peel-consent\/","title":{"rendered":"PCA Skin Peel Consent"},"content":{"rendered":"<script type=\"text\/javascript\">var 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validation_below'><div id=\"field_2_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" >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\u2010A\u00ae, Accutane\u00ae, Differin\u00ae, Tazorac\u00ae, Avage\u00ae, EpiDuoTM, or Ziana\u00ae.<br><br>\nI understand there may be some degree of discomfort such as stinging, pin\u2010prickling sensation, heat or tightness.<br><br>\nI 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.<br><br>\nI 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.<br><br>\nI 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.<br><br>\nI 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.\nI 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).<br><br>\nI 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.<br><br>\nI 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.<br><br>\nI understand that I should follow my clinician\u2019s recommendations for post\u2010procedure skin care to minimize side effects and maximize results.\nI hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post\u2010peel care instructions as I am directed.<\/div><div id=\"field_2_3\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Your Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_3_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_3_valid' id='input_2_3_valid' \/><canvas id='input_2_3' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>Signature of Clinician:<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_6_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_6_valid' id='input_2_6_valid' \/><canvas id='input_2_6' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' for='input_2_4'>Date signed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_2_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_4_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_4' class='gform_hidden' value='https:\/\/skinretreattx.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><legend class='gfield_label gform-field-label' >Have you recently used Accutane, topical medications, or antibiotics?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_7'>\n\t\t\t<div class='gchoice gchoice_2_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_2_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_7_0' id='label_2_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_2_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_7_1' id='label_2_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><legend class='gfield_label gform-field-label' >Have you recently had aesthetic fillers, injectables or laser treatments?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_8'>\n\t\t\t<div class='gchoice gchoice_2_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_2_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_8_0' id='label_2_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_2_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_8_1' id='label_2_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_9\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><strong>I acknowledge the following:<\/strong>\n<ul><li>I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take\u2010home regimen in the treated areas for minimum 2 weeks preand post\u2010treatment.\n<\/li>\n<li>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.<\/li>\n<li>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.<\/li>\n<li>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.<\/li><\/ul><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>Printed Name<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label' for='input_2_11'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_11_Container' class='gfield_signature_container ginput_container' style='height:180px; 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