Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all information detailed below *

This applies to the area that you plan to have peeled

I have not used Accutane in the last 6 months

I don't have active herpes simplex (cold sores)

I will not have any other facial treatments for at least 2 weeks after my peel or until the skin is smooth and back to normal

I have not applied Retin-A, Renova, Tazorac, and/or Differin 1 weeks prior to today and will not apply 1 weeks after my peel to the treatment

I have not sun tanned or used the tanning bed 2 weeks prior to today and will not use 2 weeks after my treatment

I have stopped any type of depilatory treatments (waxing, depilatory creams) to the area of treatment, 1 weeks prior to today and will 1 weeks after my peel

I have stopped electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of treatment, 2 weeks before today and will 2 weeks after my peel

I am not pregnant, lactating or trying to become pregnant

I am not prone to forming keloid or hypertrophic scars

I do not have history of sun allergies

I have not had prior bad reaction to a peel

I have not gone through recent radiation treatment for cancer

I do not have a sunburn or significant sun exposure in the last two day

I have not had any surgery or cryosurgery within the last month

I am not allerigic to resorcinol or salicyic acids

I will not peel, pick or scratch the treated area post peel

I will faithful use of broad spectrum UVA-UVB sun block with SPF 50

I acknowledge that immediately after the peel, my face may temporarily appear frosted or sunburned and by day two, the skin may darken in color, feel tighter and be more sensitive. Days two through approximately seven, my skin may slough.

I acknowledge that pulling or picking skin may lead to infection or scarring.

Date *

MM

DD

YYYY