Vitalize_peel.wps

VITALIZE CHEMICAL PEEL™ (Formerly Precision Peel)
INFORMATION & INFORMED CONSENT
Patients with active cold sores or warts, wounded, sunburn, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated should be excluded from the Vitalize Peel™ because the procedure could potentially precipitate a flare up or spreading. Inform the esthetician if you have any history of herpes simplex. ___________ initial Patients with a history of allergies, rashes, or other skin reactions may be sensitive to treatment. Vitalize Peel™ should not be performed on patients with an allergy to slicylates (i.e., aspirin). This peel is not recommended if you have taken Accutane within the past year, or received chemotherapy or radiation therapy. ONE WEEK BEFORE YOUR VITALIZE CHEMICAL PEEL™
Avoid the following procedures for one week prior to your peel:
a. Electrolysis b. Waxing c. Depilatory Creams d. Laser Hair Removal
TWO TO THREE DAYS BEFORE YOUR VITALIZE™
1. Stop using Retin-A, Renova, Differin (Adapalene 0.1%) or any products containing Retinol, AHA or BHA, Benzoyl AFTER YOUR VITALIZE CHEMICAL PEEL™
1. Immediately after the peel your skin will be light yellow. This is temporary and will fade 1 to
2 hours.
2. Patients with hypersensitivity to the sun should take extra precautions to guard against exposure
immediately following the procedure. They may be more sensitive following the treatment.
3. Your skin may be more red than usual for 2 to 3 days. Please avoid strenuous exercise during this time.
4. Approximately 48 hours after the treatment, your skin will start to peel. This peeling will generally last 2 to
3 days. DO NOT PICK OR PULL THE SKIN.
5. When washing your face, do not scrub. Use a mild cleanser or any other cleanser that does not contain soap.
6. Apply light moisturizer to relieve dryness and tightness.
7. Use a sunscreen with an SPF of at least 20, and avoid direct sunlight for at least one (1) week.
8. Do not have any other facial treatment for at least one (1) week after your peel.
9. You may resume the regular use of Retin-A, alpha-hydroxy acid (AHA) products or bleaching creams
ONLY after the peeling process is complete.
Call the office immediately if you have any unexpected problems after the procedure.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
I understand that the chemical peel is not an exact science and the degree of improvement is variable. ___________ Initials
I understand that occasionally there is no improvement and another form of treatment may be required. ____________ Initials
By my signature below, I acknowledge that I read “Vitalize Chemical Peel™ Information & Informed Consent” and understand it.
I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. I have been adequately
informed of the risks and benefits of this treatment and wish to proceed with the Vitalize Chemical Peel.™
______________________________________ ________________________________ _____________________
Patient Signature Print Name Date

______________________________________ ________________________________ ______________________
Witness Signature Print Name Date

Source: http://www.westsidemedicalspa.com/patient-forms/Vitalize-Peel.pdf