Dermatology Partners

Consent Form for Corrective Peel


Consent Form for Corrective Peel

I, consent to the treatment known as a corrective peel. The treatment has been explained to me, and I have had the opportunity to ask questions.

Prior to this treatment I have been candid in revealing any condition that may have a bearing on this procedure, such as cold sores, allergies, recent facial peels, surgery, use of retinol, Accutane or hormones.

The procedure may cause stinging and discomfort, usually lasting a short period of time. lt may also cause some redness. Occasionally some swelling may occur. The skin may peel and could continue to do so for up to one week.

I understand that there are potential risks and complications associated with any procedure. Although it is impossible to list every potential risk and complication, I understand that possible risks and complications from this procedure may include, but are not limited to, the following:

  • Swelling, redness, peeling or scabbing of the treated skin or surrounding areas
  • Sensitivity to wind and sun
  • New acne eruptions
  • Areas of increased or decreased pigmentation

I understand that the results of the treatment vary with each individual, and are subject to change over time.

I have been informed that the corrective peel may be part of another aesthetic treatment such as Medical Cleansing, Quench and Vibraderm.

 

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Signature Certificate
Document name: Consent Form for Corrective Peel
Unique Document ID: 1d047d699b31799484bb9d51a532aec02ef2cb4b
Timestamp Audit
May 6, 2020 3:56 pm MDTConsent Form for Corrective Peel Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138