Consent Form
Microdermabrasion,
Ultra Peel, PCA Peel, Esthetique Peel,
Oxygenating Peel, MicroPeel,
MicroPeel Plus, Glycolic Peel, Sensi Peel, Rhonda Allison Peel Solutions,
Rhonda Allison Enzyme Treatments, Deep Cleansing Facials, Signature
Facials, Waxing Procedures, and/or LAM Probe
Prior to receiving
treatment, I have been candid in revealing any condition that may have
bearing on this procedure, such as: pregnancy, recent facial surgery,
allergies, tendency to cold sores/fever blisters, use of Retin-A,
Accutane, or prescription medication.
I understand there may be some degree of discomfort; i.e.,
stinging, pinpricking sensation, hotness 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, that each case is individual.
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 multiple
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 doctor/clinician who performed the
treatment.
I understand that the use of
Sunblock protection with a Zinc Oxide or Titanium physical blocking agent
is mandatory
I have not had any other peel treatment of any kind within 14
days of the treatment. I
understand I cannot have another treatment within 14 days of this
treatment, whether the treatment is performed at this location or any
other location.
I understand that my physician or clinician may discover other,
or different conditions, which require additional or different procedures
than those planned. I authorize my
physician and clinician to perform other procedures that are advisable in
their professional judgment, upon my approval.
I acknowledge my obligation to follow the written and spoken
instructions closely given to me by my clinician.
I hereby agree to all of the above and agree to have this
treatment be performed on me.
I further agree to follow all post-peel care instructions as I am
directed.
Patient Signature:____________________________________Date:__________________
Initials:______________
Clinician Signature:__________________________________Date:__________________