Perfect Derma Peel
Consent Form
Name
Do we have your permission to show your non-identifying photos or videos for educational purposes on our social media or our before/after pictures? *
Required
Would you like to be added to our VIP client list to receive exclusive offers for those who sign up and includes specials etc. each month? If yes, enter your email below...
Today's date
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Have you ever had the Perfect Derma Peel or another chemical peel before? *
Required
The Perfect Derma Peel is a medium depth, medical grade chemical peel suitable for all skin types. The peelcontains Tricloroacetic Acid (TCA), Retinoic Acid, Kojic Acid, Salicylic Acid, Phenol, Glutathione and VitaminC *
Required
Are you pregnant? *
Required
I understand and agree to the contraindications for this treatment: *
Required
What are your main areas of concern (if any) or anything you would like to maintain *
Please read and initial the following: *
Required
By my signature below, I certify that I have read and fully understand the contents of this Informed Consent and that the disclosures referred to herein were made to me. I do not hold my Esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. Enter name below - document will be signed on the day of treatment. I agree to adhere to any home care given and will contact my Esthetician immediately with any questions or concerns. *
Date of treatment *
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