VI Peel Consent Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Please check and acknowledge the following:

Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.

I understand that there may be some degree of discomfort such as burning, stinging, redness, heat, or tightness during and a week after the procedure.

I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.

I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.

I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.

I understand that maintenance of VI Peel® treatments are necessary to maintain results as well as the recommended VI Derm® skin care regimen and SPF 50+.

I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®.

I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub, steam room, and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)

I understand that I must protect my skin with VI Derm® SPF 50+ and avoid sun exposure during the 7 day exfoliation process.

I understand that this is an elective cosmetic procedure.

I understand that no other chemical peels, facial machine brushes, or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so.

Date *

MM

DD

YYYY