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XanthRemover Professional Peel Consent Form

This form is for exclusive use of those professionals using The XanthRemover as a professional Peel in their clinics

Please feel free to use our electronic consent form here.

 

A chemical peel can be used to improve the appearance of fine lines and wrinkles, improve texture/tone, reduce
pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance
of hyper pigmentation etc. Multiple treatments maybe required in order to obtain optimal results spaced 2-6 weeks apart. Due to variables such as age, skin condition, sun damage, smoking, skin care products, climate, life-style, and general health, you
acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.

The chemical peel is used to peel away the skin’s damaged outer layers. The new cells and collagen are
stimulated during the healing process to produce a smoother, tighter, younger ­looking skin surface. A peel does
not eliminate sagging or excess skin. The depth of the peel is dependent on the way the product is used (type of protocol), the duration of peel application, and a person’s skin type and sensitivity.

 

I have been told the following:

1. No anesthesia is needed for peels.

2. The peeling agent is applied evenly to the skin surface.

4. I may experience some stinging, redness, irritation, and crusting.

5. It is common to experience some temporary flaking or scaling, redness and dryness of the skin.

6. I may immediately return to normal activities.

7. I have been instructed what to use to keep the skin clean and moist.

8. I have been instructed to begin or continue a regular program of suncreens and sun protection.

 

Contraindications:

1. Pregnancy/Lactating

2. Herpes Simplex (cold sores or fever blisters). An anti-viral medication may be necessary prior to treatment.

3. Extensive sun or tanning 3 days prior and 3 days post treatment.

4. Accutane in the past 6 months to 1 year.

5. Topical retinol products in the past 2 weeks.

6. Waxing of area to be treated in the past 7 days.

7. Any other chemical peel within 14 days of the treatment.

8. Skin must be healthy and intact.

9. An allergy to aspirin.

 

I am aware of the following risks/complications that may occur:

1. Mild to moderate discomfort or pain

2. Redness or/and swelling

3. Sun sensitivity

4. Skin sensitivity

5. Pigment changes (None reported so far)

6. Scarring (None Reported so far)

7. Allergic reaction (None Reported So Far)

8. Bacterial infection (None Reported So Far)

9. permanent discoloration (None Reported So Far)

 

 

ONE WEEK BEFORE THE  PEEL:

Avoid these products and/or procedures for one entire week prior to your chemical peel:

Electrolysis/Electrical Arcing/ Plasma etc

Waxing the area to be treatment

Hair Removal  Creams

Tanning products or treatments

Laser Treatments

Excessive Sun Exposure

Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol TWO TO THREE DAYS BEFORE YOUR PEEL: Stop using:

Any products containing AHA or BHA, or benzyl peroxide
Any exfoliating products that may be drying or irritating

 

Aftercare

It is crucial to the health of your skin and the success of your peel that these guidelines be followed:

1. If your practitioner has instructed you to remove the XanthRemover at home, you must do it exactly at the time instructed by the practitioner not later. This is because the longer you keep the product the deeper the peeling effects. You Remove the XanthRemover simply by rinsing it with water.

2 It is recommended that any hydrating soothing product rerecorded by the practitioner is applied  immediately after you removed the XanthRemover.
2. It is imperative that you use a physical sunscreen with total protection and avoid direct sunlight for at least 2 months after the treatment. Only apply the sunscreen once the exfoliation is complete. Avoid sun exposure during the exfoliation.
3. People with hypersensitivity to the sun should take extra precautions to
guard against exposure immediately following the procedure as they may
be more sensitive following the peel.
4. The skin may be more red than usual for 2-3 days. Please avoid strenuous
exercise during this time.
5. Approximately 48 hours after the treatment, the skin will start to peel. This
peeling will generally last 2 to 5 days. DO NOT PICK OR PULL THE SKIN.
6. When washing your face, do not scrub. Use a gentle cleanser.
7. Apply The appropriate aftercare as often as needed to relieve dryness and
tightness.
8. Do not have any other facial treatments for a least one week after your
peel.
9. You may resume the regular use of Retin-A, alpha-hydroxy acid (AHA), or
bleaching creams only after the peeling process is complete.

Update your practitioner daily with your pictures for the whole exfoliation duration process.

I understand that the Peel treatment is not an exact science and the degree of improvement is variable. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Clinical results will vary from person to person. I understand that occasionally there is no visible improvement and another form of treatment may be required.

I understand that the treatment may be repeated several times to achieve complete satisfaction. I understand that this treatment is voluntary on my part.

I agree to adhere to all safety precautions and regulations during the treatment and the aftercare recommendation Above. Also I agree to send photographic daily update to the aesthetic practitioner.

Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

I have been given ample opportunity for discussion and my questions have been answered to my satisfaction.

I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. This consent is valid for all of my chemical peel treatments in the future as well.