VI Peel Body Client Consult Form "*" indicates required fields Patient Name* Date* MM slash DD slash YYYY Email* Phone*The VI Peel® contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel® will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne 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 (i.e. Lupus) or liver disease/disorder as well as any condition that may weaken their immune system Consent* Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.*Consent* 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.*Consent* 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.*Consent* 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.*Consent* 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.*Consent* I understand that maintenance of VI Peel® treatments are necessary to maintain results as well as the recommended VI Derm® skin care regimen and SPF 50+.*Consent* I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®.*Consent* I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub steam room and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)*Consent* I understand that I must protect my skin with VI Derm® SPF 50+and avoid sun exposure during the 7 day exfoliation process.*Consent* I understand that this is an elective cosmetic procedure.*Consent* 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. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.*Printed Patient Name* Patient Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Printed Practitioner Name* Practitioner Signature Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY PEEL TYPE: LOT # EXP DATE: MM slash DD slash YYYY CAPTCHA Δ
