Chemical Peel Consent Form

Chemical peels are cosmetic treatments designed to improve the appearance and condition of your skin. These treatments can help reduce the appearance of fine lines and wrinkles, improve texture and tone, minimise pore size, enhance hydration and moisture retention, smooth the skin’s surface, and reduce hyperpigmentation. The procedure involves applying layers of specialised chemical products tailored to your unique skin composition and needs. Multiple treatments spaced 2-6 weeks apart are often necessary for optimal results.

It is important to note that individual results can vary depending on factors such as age, skin condition, sun exposure, lifestyle habits, and overall health. No guarantees, warranties, or assurances can be made regarding the results of this treatment.

Contraindications

Please inform your practitioner if any of the following apply to you, as they may preclude or delay treatment:

  • Pregnancy or breastfeeding.
  • Active herpes simplex (cold sores or fever blisters). An antiviral medication may be required prior to treatment.
  • Recent extensive sun exposure or tanning (within 3 days before or after treatment).
  • Use of Accutane (oral isotretinoin) within the past 6-12 months.
  • Use of topical retinol products in the past 2 weeks.
  • Waxing or hair removal treatments in the treatment area within the past 7 days.
  • Another chemical peel or resurfacing procedure performed within the past 14 days.
  • Unhealthy or damaged skin in the treatment area.
  • Known allergy to aspirin or salicylic acid.
Potential Risks and Complications

While chemical peels are generally safe, there are potential risks and side effects, which include but are not limited to:

  • Mild to moderate discomfort, tingling, or burning sensations during or after the procedure.
  • Temporary redness, swelling, or flaking of the skin.
  • Increased sensitivity to sunlight (photosensitivity).
  • Skin irritation or heightened sensitivity.
  • Hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), particularly for individuals with darker skin tones.
  • Scarring (rare but possible, particularly with deeper peels).
  • Allergic reactions to the peeling agents or other products used.
  • Bacterial, viral, or fungal infections if post-treatment care instructions are not followed properly.
Acknowledgment and Consent

I understand that chemical peel treatments involve risks of complications or injury from both known and unknown causes. I accept these risks and consent to proceed with the treatment. I confirm that I have provided complete and accurate information regarding my medical history and any conditions that may affect this procedure.

I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I understand that individual results may vary, and no guarantees have been made regarding the outcome of the treatment. I agree to follow the pre- and post-treatment care instructions provided by my practitioner to minimise the risk of complications.

I consent and authorise Dr. Maria Mackey and/or her designated medical professionals at Mojo Cosmetic Clinic to perform one or more chemical peels on me. I release Dr. Maria Mackey, her associates, and Mojo Cosmetic Clinic from all liabilities associated with this procedure. This consent remains valid for all future chemical peel treatments unless revoked in writing.

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