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Consent to dermaplane and/or chemical acid peel procedure for cosmetic purposes

Consent to Dermaplane and/or Chemical Acid Peel and/or Microdermabrasion Procedure
for Cosmetic Purposes
1. I hereby request and authorize Patricia Giordano to treat me for the purpose of attempting to 2. The effect and nature of the treatment to be given has been explained to me. I acknowledge that the goal of the treatment is to induce improvements in my skin, but individual results may vary. 3. I acknowledge that no guarantee has been given to me as to the number of months/years that I may 4. I acknowledge that no guarantee has been given to me as to the amount of improvement expected 5. I acknowledge that no guarantee has been given to me as to the painlessness of the procedure. 6. I have been advised to see my physician regarding a preventative anti-viral prescription if I am prone to Herpetic outbreaks (cold sores/fever blisters). I understand that acid treatments and/or dermaplaning may cause a flare-up of the Herpes Simplex virus. 7. I have been advised to avoid or discontinue the following treatments for five (5) days prior to my  Botox injections  Filler injections  Retin-A, Renova and all retinotic acid products  All alpha and beta hydroxyl acid products 8. I have been advised that a period of three (3) days must elapse before I can resume the use of the  Filler injections  Retin-A, Renova and all retinotic acid products  All alpha and beta hydroxyl acid products 9. I acknowledge that I have not taken Accutane in the past 12 months. I further agree not to take
Accutane during my treatment program at this practice and for six (6) months after ending my treatment at this practice. 10. I understand that I must apply a hypoallergenic, hydrating, antioxidant topical preparation to encourage epidermal regeneration for at least seven (7) days post procedure. 11. I have been advised that a broad- spectrum sunscreen must be used from the date of my first treatment and continued daily thereafter. I agree to apply a broad-spectrum sunscreen daily ____________ (initial) 12. The following conditions (including, but not limited to) listed below are not treatable with
dermaplaning and/or acid peeling solutions: impetigo, inflamed eczema, herpes simplex, severely distended capillaries, dermatitis, questionable lesions and sunburn. 13. Possible side effects from treatment are: local swelling, stinging, tenderness, flaking, peeling,
lightening or darkening of the skin and/or mild to moderate redness. It is possible that one or more of these side effects may last for two (2) to seven (7) days post procedure. However, must subside within 24 hours. 14. I certify that all information to Patricia Giordano is true and accurate. I agree to follow the protocol outlined above. I agree to hold harmless Patricia Giordano for adverse reactions due to omitted information and/or misinformation on the Patient Health Information Questionnaire and/or from actions, which deviate from pre and post care procedures. _____________________________________________________ ________________ _____________________________________________________ ________________ Signature of Parent or Guardian if client is under 18 years of age Date

Source: http://www.healthyskin.skincaretherapy.net/Healthy_Skin_Consent_Form.pdf

t-coe.org.uk

Clinical Senior Lecturer in Ageing and Health The evidence }  There is evidence that medication review in older people can lead to an improvement in the appropriateness of prescribing }  There is evidence that these changes persist (at least out to 6 months) }  There is very little evidence that this process reduces adverse drug events, hospitalisation, or improves quality

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