Informed Treatment Book AppointmentInformed Treatment Consent FormInformed Treatment ConsentName(Required) First Last Date(Required) MM slash DD slash YYYY Treatment(Required)The instructions and guidelines provided in this informed consent should be followed by all individuals receiving a Professional Resurfacing Treatment Please read and initial after each paragraph acknowledging that you have read and understood all of the information presented.PROFESSIONAL RESURFACING TREATMENT1(Required) I consent that...This Professional Resurfacing Treatment is a superficial peel designed to improve the texture and appearance of your skin. Your participation in your treatment will determine the outcome. It is important that you strictly adhere to all instructions that your treatment specialist has provided.2(Required) I consent that...No guarantee is expressed or implied as to the precise results, peeling times, or discomfort.3(Required) I consent that... Depending on the treatment, you may experience some temporary redness, stinging, or warm flushing. During the next few hours, you may experience some tightening of the skin which may last for several days.4(Required) I consent that...For most individuals, a light flaking begins within 48 hours. It is impossible to pre-determine how much peeling will occur.5(Required) I consent that...Dark spots may appear darker before shedding off.6(Required) I consent that...Depending on the treatment, the shedding process usually subsides within 2-7 days.7(Required) I consent that...Lack of flaking or peeling is NOT an indication that the treatment was unsuccessful. If you do not notice actual peeling you are still receiving all the benefits of your treatment such as improvement of skin tone, texture, and appearance of fine lines and hyperpigmentation. There are a number of reasons why some people may not experience peeling such as severe sun damage, having peels regularly with short intervals between treatments, and frequent use of Retin-A, Retinol, or AHAs.8(Required) I consent that...Depending on the treatment performed and your individual skin health, the following reactions may occur in some individuals: Prolonged redness, irritation, flakiness, dryness, sensitivity, and in rare instances severe allergic reactions.INDIVIDUALS WHO SHOULD NOT BE TREATED1(Required) I consent that...A Professional Resurfacing Treatment SHOULD NOT be performed on people with active cold sores or warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis or inflammatory Rosacea in the area to be treated, or an autoimmune disease.2(Required) I consent that...You should not have a Professional Resurfacing Treatment if you have a history of allergies, rashes, other skin reactions, cancer, or may be sensitive to any components of this treatment.3(Required) I consent that...This treatment is not recommended if you have taken Accutane (or its generic form) within the past year, or received chemotherapy or radiation therapy.4(Required) I consent that...With the exception of Lira Clinical's Beta-C Plus, Vita Brite Refresher with PSC and Pumpkin Plus Definer with PSC treatments, this treatment should not be administered to pregnant or breastfeeding (lactating) women.Inform your treatment specialist if you have any of the above concerns, a history of herpes simplex, or are allergic to aspirin.PRE-TREATMENT GUIDELINESUnless otherwise instructed to do so by your treatment specialist:1(Required) I consent that...One week prior to treatment avoid waxing, electrolysis, Laser Hair Removal, prescription retinoids/retinoid-like compounds (Retin-A, Renova, Differin, Tazorac), products containing Retinol, AHAs, BHAs, Benzoyl Peroxide, or any exfoliating products that may be drying or Irritating on the area to be treated.2(Required) I consent that...Individuals who have medical cosmetic facial procedures must wait until skin sensitivity completely resolves before having a Professional Resurfacing Treatment.POST TREATMENT GUIDELINESIt is crucial to the health of your skin and success of your treatment that these guidelines be followed:1(Required) I consent that...It is imperative that you use the prescribed Lira Clinical BIO Recover Kit to heal and protect the skin which includes mandatory daily sun protection.2(Required) I consent that...I will avoid direct sun exposure for at least 48 hours.3(Required) I consent that...Your skin may be more sensitive after your treatment so avoid strenuous exercise for at least 24 hours.4(Required) I consent that...I will not pick or pull the skin.5(Required) I consent that...When cleansing, I will not scrub or use a wash cloth.6(Required) I consent that...Wait until all flaking and peeling is complete before returning to your regular home care routine or having additional professional treatments.7(Required) I consent that...I will Immediately notify my treatment specialist of any concerns.ConsentI hereby give my consent & authorization, and voluntarily release...from any claims implied or stated that I have or may have in the future with this treatment, regardless of result. I am stating that the treatment and precautions above have been explained to me in detail and that I fully understand. If I am under the care of a physician, I have discussed the treatment plan with my physician for prior approvalSignatureDate MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
