Online Chemical peel consultation and consent form Chemical peel consultation and consent form Please answer all questions. How did you hear about us? Full Name Date of Birth Address Contact Number Email Are you taking any medication? YesNo Please provide list of medication: This is an informed consent document which has been prepared to assist your skincare specialist to inform you about skin peel and skin treatment procedure(s), its risks and alternative treatments. It is very important that you read this information carefully and completely. Although it is impossible to list every potential risk and complication the following conditions are recognized as contraindications for skin peel treatment and must be disclosed and discussed with the specialist prior to treatment. Do you have any of the following contraindication Roaccutane or Accutane within the last 6 months YesNo Active herpes simplex {cold sores} YesNo Facial warts YesNo Are you currently pregnant YesNo Keloid or hypertrophic scars YesNo History of sun allergies YesNo Prior bad reaction to a facial peel YesNo Recent radiation treatment for cancer YesNo Allergic with salicylic acids YesNo Diabetes YesNo Inflammation/irritation/infection of the skin YesNo If you have ticked any of the above contraindication, please give details below:: I understand that results may vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome I agree that I have read and understand this consent form and all the information above. I understand that this procedure is purely elective. This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.
Recent Comments