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DermaQuest Facial/Skin Peel
Are you prgnant/lactating
Skin Type
Skin Concerns
Please select any treatmens you have previously had
Do you currently use/or hve you ever used
Health - please answer yes or no to the below questions
Have you ever had an alergc reaction to any cosmetic product/medicaton/
Please tick any of the below that apply to you
Which fitzpatrick skin type are you?
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The section below is for advanced peels, if you have been asked to prep your skin at home with selected products please complete the questions below. If you are not using products at home to prep your skin you can now go to the bottom of this page to sign and submit this form.
Cleansers and Treatment Cleasers
Serums, Creams and SPF

Informed Consent for Advanced Treatments:

I acknowledge that no guarantee has been made regarding the results of this procedure. Although it is impossible to list every potential risk and complication, I have been informed of the possible risks and complications which may include, but are not limited to the following:

  • Stinging, itching or irritation

  • Redness and swelling of the skin

  • Tightness, peeling or scabbing of treated skin and surrounding areas

  • Skin sensitivity to wind, sun or other environmental factors

  • Darkened pigmentation

  • Any potential risks and complications could result in the need to discontinue the treatment. In this case, alternative recommendations will be suggested It is very rare that a permanent disability occurs. In case of complication during or after the treatment, I authorise my aesthetician to perform any necessary treatments.

I certify that I am at least eighteen (18) years old.
I confirm I have informed my aesthetician of the following:

  • My diagnosis of diabetes

  • That I am a patient under a physicians care

  • My use of all medications and supplements, including antibiotics

  • My use of Isotretinoin (Accutane) in the past 12 months

  • Any history of radiation to the region

  • Herpes simplex or active infection

  • My history of hypertrophic scar formation

I agree to the following:
• That I am not pregnant or breastfeeding

  • That I have not used Retinoids, Hydroxy Acids or Benzoyl Peroxide for at least one week

  • That I will not use Retinoids, Hydroxy Acids or Benzoyl Peroxide until my skin is healed

  • That I have not waxed in the past week, or shaved the treated area for 24 hours

  • That I will avoid hot baths/showers, sweating and strenuous exercise for one week post procedure

  • That I will avoid rubbing, picking and scrubbing my skin post procedure, as it may result in scarring, hyperpigmentation or other skin damage

  • That I will protect my skin from any sun exposure with a broad spectrum sunscreen of at least SPF 30 daily

  • I have received a patch test prior to my treatment, I have read and will follow any and all instructions to the best of my ability

  • I understand the potential risks and complications, and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives.

Please selet the box to confirm you have taken a patch test and had no reaction
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