VI Peel CONSENT FORM #1


Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: Pregnancy (if so consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, use of topical ingredients that contain retinol, AHA’s or the like, use of acne medications or other skin medications including Retin-A, Accutane, Differin, Tazorac or the like.

I understand that there may be some degree of discomfort; i.e. stinging, pin-pricking sensation, hotness, or tightness.

I understand there are no guarantees as to the results of the treatment, due to many variables, such as age, condition of the skin, sun damage, smoking, climate, etc. I understand I may or may not actually peel, that each case is individual.

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.

I understand that to achieve maximum results, I may need several treatments.

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In an event of any complications, I will immediately contact Nance Jack who performed the treatment.

I agree to refrain from tanning whether outside or in tanning booths while I am undergoing treatment, and during the 14 days following the end of treatment.

I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of a broad spectrum sunblock with a minimum of SPF 15 is mandatory.

I have not had any other chemical peels of any kind, within 14 days of the treatment. I understand that I cannot have another treatment within 14 days of this treatment, whether it is performed at this location or any other location.

I hereby agree to all of the above and agree to have this treatment performed on me. I have informed Nance Jack-Garber of any and everything that could have bearings on my treatment today. I further agree to follow all post peel care instructions as I am directed.


Signature: __________________________________ Date: _____________


Nance Jack: _________________________________ Date: _____________