TREATMENT CONSENT FORM
Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy, nursing (if so, consult your physician prior treatment), recent facial surgery, allergies, tendency to cold sores/ fever blisters, use of the following medications or similar; Retin-A/Renova®, Differin®, Tazorac®, Avage®, EpiDuoTM, or Ziana®, Minocycline, Accutane®, or products that contain Glycolic acid.
I understand there may be some degree of discomfort: i.e., stinging, pin-pricking sensation, hotness, or tightness.
I understand I may or may not actually peel and that each case is different.
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 and I need to follow the maintenance home protocol as instructed since homecare maintenance is part of the process.
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I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the doctor/technician who performed the treatment.
I agree to refrain from tanning in tanning booths while I am undergoing treatment, and during the completion of the treatment.
I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum of SPF 30 is mandatory.
I have not had any other chemical peels of any kind, within 14 days of the treatment.
I understand I cannot have another treatment within 14 days of this treatment, whether it is performed at this location or any other location.
I understand that I must refrain from waxing or the use of other depilatory products for 7 days prior to treatment. While maintaining chemical exfoliation treatments or treatments for Hyperpigmentation, discontinue use for 3 days prior to waxing and do not re-introduce for 3 days after waxing.
I understand that I am advised not to do any type of exercise, cooking, cleaning, or anything that may bring heat to my body and skin during the time that I am wearing the cosmelan #1 mask.
I am aware that Cosmelan MD #2 home maintenance that has been compounded with Hydroquinone is advised not to be used longer than a span of 4 months and continued maintenance with Cosmelan #2 regular formulation without Hydroquinone is recommended.
GUARANTEE. By agreeing to this consent, I understand there is no guarantee, warranty, or assurance made to me as to the results. I understand clinical results vary by patient and depend on lifestyle habits including but not limited to age, condition of skin, sun damage and exposure to sun, smoking, climate, diet (i.e. consumption of alcohol, sugar, water, etc.) exercise, stress, and sleep patterns.
CONSENT. I declare that I have read, agree, and fully understand the above information. I hereby agree to have this treatment performed on me. I agree to adhere to all safety precautions and regulations during treatment. I further agree to follow all post care instructions as I am directed.
CERTIFICATION. I certify that I am a competent adult of at least 18 years of age, of that if I am a minor under the age of eighteen; I understand that the consent of my parent/legal guardian/person having legal custody will also be required to sign before treatment. My consent for this treatment has been fully informed, is freely and voluntarily executed and shall be binding.
CONSENT TO PHOTOGRAPH. I further consent to have my photograph taken before, during, and after the treatments. These photographs shall be the property of Xtetic World and may be published for educational purposes.
I certify I have read and initialed the above paragraphs. I have been explained its content to my full understanding and release Xtetic World, their instructors and employees of any and all liabilities while receiving and/or performing any cosmetic procedures, nor will I hold them responsible for any unforeseen condition arising out of the indicated procedure.
My questions about the procedure have been answered satisfactorily. I understand the procedure and accept the risks.
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CONTRAINDICATIONS
Do not have Botox®, Restylane®, Collagen or other dermal filler for a minimum of 2 weeks post treatment.
Do not go swimming for 48 to 72 hours after treatment.
Do not go to tanning beds two weeks prior to treatment or 2 weeks post treatment. It is recommended that prolonged sun exposure be avoided for at least 10 days prior to any professional treatment.
Do not use other skin lightening agents for the duration of treatment.(i.e.; Hydroquinone, Kojic acid, Azelaic acid, Arbutin, Retin-a etc…)
Discontinue use of Glycolic Acid products 7 days prior to treatment and do not re-introduce into skin care regimen for 30 days post treatment.
It is not recommended to have professional chemical exfoliation treatments if you are pregnant or nursing, consult with OB/GYN prior to any aesthetic treatment.
