Reemake Skin Medical Spa + Laser Clinic

REEMAKE SKIN

The Perfect Derma Peel Consent Form:

The Perfect Derma Peel is a medium depth, medical grade chemical peel suitable for all skin types. The peel contains Trichlorocacetic Acid (TCA), Retinoic Acid, Kojic Acid, Salicylic Acid, Phenol, Glutathione and Vitamin C.

Contraindications:

• Patients who are pregnant or breast feeding

• Patients with allergy to any peel ingredients listed above or to aspirin

• Patients who have used Accutane within the past 4 months

• Patients who have open wounds, sunburn, infected skin, cold sores or lesions. Patients with a history of cold sores (herpes simplex) may be given an antiviral 3 days prior to peel

• Patients who have recently had treatments such as waxing, electrolysis or chemical exfoliants

• Patients who are undergoing chemotherapy and/or radiation therapy

• Patients with a history of autoimmune disease or any condition that may weaken the immune system

Please read and initial the following:

1. Prior to receiving treatment I have informed REEMAKE staff about any medication for health conditions that may contraindicate this treatment.

2. I understand that there might be some discomfort such as stinging, redness, burning, itchiness or tightness during and a week after the treatment. I understand that it sis important not to pull, pick at or remove peeling skin forcibly.

3. I understand that there is no specific guarantee as to the final results of the peel, and that may require more than 1 treatment for optimal results.

4. I understand that while complications are extremely rare, they may occur. In the event of a reaction or complication, I agree to immediately contact my medical professional for follow up care.

5. Occasionally hyper pigmentation or hypo pigmentation may develop which can persist for weeks or months after the treatment.

6. I understand that post peel care includes the use of Mineral Perfection SPF 30 or an SPF 30 or above and avoid sun exposure during the exfoliation process.

7. I understand that extended sun exposure, including use of tanning beds, is prohibited both before and after The Perfect Derma Peel Treatment. Avoid sweating excessively or use of steam/sauna 3 days post peel.

8. I understand that this is an elective procedure and is non refundable.

9. I understand that no other chemical peels or medical device treatments are to be performed on my skin until REEMAKE technicians release me to do so.

I consent and authorize the staff at Reemake Skin to perform the Perfect Derma Peel treatment on me. I hereby release the staff at Reemake Skin from all liabilities associated with this procedure. This consent form is valid for all future Perfect Derma Peel treatments.

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