Perfect 10 Peel Consent Form - Amenity Day Spa
44365 Premier Plaza, Suite 120, Ashburn, Virginia 20147

Perfect 10 Peel Consent Form

This form is designed to provide you with information for making an informed design regarding your chemical peel. Please do not hesitate to ask a member of our staff any questions you may have. While a chemical peel is effective in most cases, no guarantee can be made that a specific individual will benefit from the treatment.

The following can be expected after undergoing a chemical peel:

  • Immediate pinkness of the skin, giving it a “rosy” glow for the first 1-2 days
  • Tight feeling of the skin for 2-3 days
  • Peeling or flaking of the skin starting 2-3 days following the peel, which can continue up to 7-10 days
  • Swelling, particularly around the eyes
  • Dryness and itching of the skin

CONTRAINDICATIONS

  • Contraindications include, but are not limited to pregnancy, nursing mothers, rosacea, atopic dermatitis, seborrhea, connective tissue diseases (ex. Scieroderma), active inflammatory acne, active inflammatory acne, active herpes, warts, active viral infections, recent surgery or invasive procedures in the area to be peeled, patients prone to keloid formation
  • Patients with history of our potential for hypopigmentation or hyperpigmentation, or for use on Fitzpatrick IV-V-VI skin types
  • Patients who have previously not tolerated topical retinoids, alpha or beta hydroxy acid products are not candidates for the Perfect 10 Peel
  • Patients that are on Isotretinoin should wait 3 to 6 months after their last dose to make sure their skin is no longer dry, red or peeling
  • Patients undergoing radiation and or chemotherapy treatments should wait until they have healed
  • Patients who have had their hair dyed or treated should wait 2-3 days after treatment
  • Patients who have waxed or used depilatory products such as Nair should wait 3 days before being peeled
  • Laser treatment – following laser treatment, clients should wait until their skin has returned to normal before being peeled

POSSIBLE COMPLICATIONS

Complications could potentially occur with chemical peels. Careful attention to instructions given is imperative. Contact the office immediately if any of the following occur:

  • Skin infection (pus, oozing, fever)
  • Appearance of a cold sore on the lips or any other portion of the peeled area (Note: the cold sore can spread if not cared for immediately)
  • Allergic reaction, acne, or irritation
  • Wind or sun sensitivity; sun may increase the possibility of swelling an redness
  • Extreme reactions, such as scarring or keloids
  • Increase or decrease in skin pigmentation, which does not blend with normal skin after healing from treatment
  • Itching, erythema, swelling

PATIENT CONSENT

My Amenity Day Spa technician has explained to me the possible complications from the proposed chemical peel and I have had sufficient opportunity to ask questions. I understand that the chemical peel treatment can cause a burning sensation. Multiple peels may be necessary to achieve the desired results, depending on my skin type and the nature of my skin problem. The degree of clinical improvement that is observed after chemical peeling can vary as aesthetic treatment results are not always consistent. After receiving and understanding in full all the information presented above, I freely give my consent to undergo the chemical peel procedure. I also consent to the taking of photographs to track my treatment progress. I understand that this procedure is cosmetic and that payment is my responsibility. My questions have been answered by the technician to my complete satisfaction. I accept the risks and potential complications of the procedure.

I understand that photographs may be taken and agree to waive ownership of these photographs, and allow Amenity Day Spa to copyright, publish, or use these photographs, and allow Amenity Day Spa to copyright, publish, or use these photographs in conjunction with presenting case study results.

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