Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of chemical peel treatment. This material serves as a supplement to the discussion you have with your Bloom Health provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the treatment, ask your Bloom Health provider prior to submitting this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
Chemical peels are used for numerous purposes, including reduction of fine lines, wrinkles, scarring, hyperpigmentation, and skin rejuvenation and skin tightening. Chemical peels are a form of chemical exfoliation, and are used to slough off the dull, top layers of skin, and stimulate fresh healthy skin cells underneath. This accelerates cell turnover and stimulation of collagen-making cells. The depth and intensity of the peel depends on the specific type of chemical solution used, and the technique of application. You may experience some stinging or burning during application of the peel, but overall, treatment is usually tolerated without significant difficulty. Following the procedure, a skin peeling effect is normal, and the skin may feel tight, dry, and sensitive to touch for a number of days. For some patients, especially darker skin types, we may advise a specific pre- and post treatment skincare regimen, in order to calm melanocytes and avoid post-treatment hyperpigmentation.
TREATMENT RESULTS
Most patients are pleased with the results of their chemical peel treatment. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that your skin condition will disappear completely, or that you will not require additional treatment to achieve the results you seek. Multiple treatments are needed to achieve a full effect, with a usual recommendation of 3-6 treatments, spaced a number of weeks apart. Additional treatments may be required periodically, generally every 6-12 months. The results of treatment are dependent on many factors including but not limited to: age, sex, tissue conditions, your general health and lifestyle conditions, and sun exposure.
AFTERCARE INSTRUCTIONS
Following your chemical peel, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) Await the recommended amount of time to cleanse your face (this will depend on the specific type of peel used); 2) Use a gentle cleanser twice daily, and apply calming moisturizer with SPF as often as needed; 3) Apply any recommended post-peel towelettes or topical hydrocortisone as directed; 4) Okay to resume hydroquinone or tretinoin after 48 hours; 5) Avoid vigorous exercise, sauna, jacuzzi or swimming for 72 hours; 6) Okay to resume regular makeup once skin flaking has subsided; 7) Avoid intentional sun exposure for at least 2 weeks; 8) Abstain from facial laser treatments, microdermabrasion and microneedling for at least 2 weeks; 9) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., Bloom Health, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy. There are certain inherent and potential risks and side effects in any dermatologic procedure, and in this specific instance such risks include but are not limited to: 1) Temporary redness and mild sunburn-like effect; 2) Flaking or dryness of the skin, and in rare cases scab formation; 3) Scarring (usually from picking prematurely at the skin); 4) Rarely, post treatment bacterial, and/or fungal infection requiring further treatment; 5) Post-inflammatory hyperpigmentation which can occur infrequently, and may resolve or remain permanent, and may require further treatment and follow-up; 6) Post treatment discomfort/swelling.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have active herpes, active cold sores, psoriasis, warts, raised moles, sunburn, or active skin infection. I have not taken Accutane in the past six months. I have not had laser treatment, waxing, or microneedling in the last week.
ALTERNATIVE THERAPY
I understand that this is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other available therapies might include sun protection, moisturizers, injectables, skin resurfacing, or surgery.
PAYMENT
I understand that my chemical peel treatment is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue my chemical peel treatment at any time.
RELEASE OF LIABILITY
I hereby indemnify Bloom Health, PLLC from any liability relating to the treatments that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to treatment with chemical peel for the purpose of general skin rejuvenation and improvement of wrinkles, hyperpigmentation, scarring and acne, as performed by my Bloom Health provider and assistant technicians. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future chemical peel treatments I choose to receive from Bloom Health.
