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Consent
form for Glycolic, AHA, and light peeling procedures
Prior to receiving this 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/Renova, Accutane or hormones. I
understand there may be some degree of minor discomfort, i.e., stinging,
pinpricking sensation, hotness, and tightness. I
understand this treatment is a strictly cosmetic procedure and that no medical
claims are expressed or implied. I understand that to achieve maximum results, I may need several ongoing treatments over a period of time. I
understand that although complications are very rare, some times they may occur
and that prompt treatment is necessary. In
the event of any complications, I will immediately contact the aesthetician who
performed this procedure. I
understand I cannot have another treatment within 14 days of this procedure,
whether the treatment is performed at this location or at any other facility. I
hereby agree to all of the above and to have this treatment be performed on me
and to follow all prescribed directions regarding post peel care. Signature_________________________________
Date _______________ Signature
of aesthetician _________________________________ |
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