Name *

First Name

Last Name

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I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin. Some of the benefits include lessening of pigmentation, reduction in appearance of fine lines and wrinkles, and control of certain conditions such as acne or occasional breakouts.

I understand that I am to complete a medical history and be complete and truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I have been candid in revealing any condition that could prohibit this treatment. I am also aware that my lifestyle, when it includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption, poor nutritional intake, and/or recreational use of controlled substances, will effect and diminish the effectiveness and results of this treatment.

I understand there is a possibility of side effects or complications can occur: Discomfort • Infection • Redness & Swelling • Scarring • Hypopigmentation • Hyperpigmentation • Itching or Irritation • Acne or Milia Breakout • Skin Peeling or Flaking up to 14 Days After the Procedure

I understand that although complications are very rare, on occasion, they may occur requiring prompt treatment. In the event of any complication, I will immediately contact the doctor/technician who performed the treatment.

I agree to refrain from excessive sun exposure or the use of a tanning bed while I am undergoing treatment and during the 14 days following the end of the treatment.

I have not had any other peel treatment of any kind within 14 days of 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.

If I have any questions regarding the procedure, I agree to call Monique Westfall at 925-872-2511 to discuss any concerns.

I understand that to achieve maximum results the recommended home care routine must be followed. I understand that if I modify the routine or use products not recommended by the skin care professional the results could be altered or inhibited. I also understand that it may take several treatments to obtain the desired results.

I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sunscreen protection with a minimum SPF 15 is mandatory.

I understand that the following conditions preclude me from having this treatment at this time and verify that none of these conditions apply to me at this time.

Check All that Apply

Allergic to Aspirin or any Salicylic Sensitivity (Salicylic Acid)

Broken Skin

Inflammation

Recent Peels Within Eight Weeks

Herpes Virus (Cold Sores)

Use of Accutane within the Past 12 Months

Use of Glycolic Acid Products, Retin-A or Renova™ in the last 4 weeks

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