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Birch Skin Studio Chemical Peel Consent Form

Do not use prescriptive topicals, abrasive scrubs or stronger exfoliants 3-5 days pre and post treatments. No prolonged sun exposure 2 weeks prior to or 2 weeks post treatments. Sun protection of at least SPF 15 will be worn whenever outdoors and re-applied frequently. I am currently not taking or using any medications that are contraindicated to receiving a chemical peel. i.e. ACCUTANE
Informed Consent
Superficial chemical peels are topical exfoliants applied to the skin to soften the dead skin layer and
exfoliate the skin. Stimulating cell turnover will help to restore the skin to a more youthful appearance. Many skin conditions can be improved when receiving a series of peels. Fine lines will be softened, dull skin will appear more radiant, rough or uneven skin will become smoother. Sun damaged skin or blotchy skin will even out. Acne scarring may be softened. Because these peels are superficial there is no downtime. I am currently not taking or using any medications that are contraindicated to receiving a chemical peel. i.e. ACCUTANE I understand that anytime the skin barrier is compromised; there is a small risk of infection. I will contact my esthetician immediately should this happen. I understand that following the treatment my skin may appear red and feel like it has a slight sunburn. Possible side effects include and are not limited to: slight or extreme redness, swelling, stinging, itchy, tenderness, dry or flaking skin. I UNDERSTAND THAT I AM NOT TO PICK THE FLAKING SKIN AS THIS COULD CAUSE UNWANTED PIGMENTATION. Most side effects will gradually diminish over time as healing may take several days or longer. The chemical peel treatment has been fully explained and any questions or concerns that I have, have been addressed. I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual's unique reactions. I understand that no specific results are guaranteed. I understand and acknowledge that there are risks involved with the Chemical Peel procedure, including but not limited to those side effects listed above. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand that any false or misleading information I have given may lead to undesired results and complications and hereby waive Birch Skin Studio’s liability if such results or complications occur. I further understand that my failure to follow post care instructions may also lead to undesired results, complications or effects and hereby waive Birch Skin Studio liability if such results or complications occur. In consideration for Birch Skin Studio performing this procedure, I agree that I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing this procedure or side effects I may experience after the procedure is performed. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against Birch Skin Studio, its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of this procedure. Patient's Signature: ________________________________________ Date: ____________ Esthetician Signature: ______________________________________
Chemical Peel Pre-Treatment Care
• Stop using Accutane 1 year prior to the treatment.
• Stop any type of exfoliating treatment(s) to the area of treatment, 2-4 weeks
prior and after your peel. Gel Peels: You can combine them with any type of facial or
Microdermabrasion treatments
• Stop applying Retin-A, Renova, Tazorac, and Differin 2 weeks prior and after, to
the treatment area.
• Stop sun tanning or using the tanning bed 2-4 weeks prior and after, to your
treatment area.
• Stop any type of depilatory treatments (waxing, depilatory creams) to the area of
treatment, 2 weeks prior & 2 weeks after your peel.
• Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the
area of treatment, 2-4 weeks before & after your peel.

Chemical Peels Post Treatment Care

• Please use the Image Post Peel Kit that was given to you after your peel. The kit includes a week supply
of balancing cleanser, Hydrating Enzyme Mask, Lightening Serum, MAX Cream and Ultimate Preventative
SPF 35.
• When cleansing, do not scrub.
• Each peel will have different results.
• Possible side-effects include but are not limited to:
• Skin may appear moderately to extremely red and feel like it has a slight sunburn. • Swelling stinging, itchy, tenderness, dry or flaking skin. • In some rare occasions a peel can penetrate deeper in certain areas and may cause a crusted scab to form. If this should happen please contact Birch Skin Studio. • Some peels may not cause the skin to peel. • Skin starts to peel 2-3 days after the peel or flake and will continue to peel or flake for 2 more days. • Do not peel, pick or scratch the treated area, as this may result in scarring or hyperpigmentation. • You may apply polysporin, bacitracin or Vaseline to dry flaky areas. • Do not have other facial treatments for at least 2 weeks after your peel or until the skin is smooth and back to normal. • Always wear your sunscreen, apply Ultimate Preventative SPF 35 every morning.

Source: http://birchskinstudio.com/uploads/3/0/3/7/3037661/birch_skin_studio_chemical_peel_consent_form.pdf