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V.I. Peel Consent

The VI Peel™ contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peels™ will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acneic skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.

 

Contraindications:

• Patients who are pregnant or who are breast feeding

• Patients who have an aspirin, hydroquinone or phenol allergy

• Patients who have used oral isotretinoin (Accutane) within the past 6 months

• Patients who have active cold sores, warts, open wounds or history of herpes simplex

• Patients who are undergoing chemotherapy and or radiation therapy within 6 months

• Patients with a history of an autoimmune or liver disease/disorder as well as any condition that may weaken their immune system

 

Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure. 

 

I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during and a week after the procedure.

 

I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel. 

 

I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment. 

 

I understand if I have any acne condition in the skin the peel may bring out oils and bacteria from below the surface and can cause an actual breakout. 

 

I understand that maintenance of VI Peel™ treatments are necessary to maintain results as well as the recommended VI DERM™ skin care regimen and SPF50+.

 

I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel™.

 

I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub steam room)

 

I understand that I must protect my skin with VI DERM™ SPF 50+and avoid sun exposure during the 7 day exfoliation process. 

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I understand that this is an elective cosmetic procedure.

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I understand that no other chemical peels, facial machine brushes or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so.

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Thank you!

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