PERFECT DERMA PEEL INFORMATION AND CONSENT FORM

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The Perfect Derma Peel is a medium depth, medical grade peel featuring the master antioxidant Glutathione. It is safe for all skin types.

Treats all skin conditions with superior results for:

• Acne

• Hyperpigmentation

• Texture

• Aging skin

• Hyperpigmentation

• Pore reduction

• Mild rosacea

• Dry, rough body areas

Key Ingredients:

A synergistic blend of acids to reach the papillary dermis. pH of The Perfect Derma™ Peel 1.3-1.4

• Trichloroacetic Acid (TCA)- chemical providing excellent skin exfoliation and resurfacing while

stimulating collagen to repair the skin

• Phenol - a chemical that can trap free radicals, exfoliates and numbs the skin

• Retinoic Acid (Vitamin A) - exfoliates, normalizes cell turnover, and promotes collagen and elastin

production

• Salicylic Acid - digests surface cells, has anti-inflammatory properties with anti-acne benefits by

clearing clogged pores

• L-Ascorbic Acid (Vitamin C) - anti-oxidant and skin brighter also protecting the skin from UV damage

while stimulating collagen production

• Glutathione - powerful anti-oxidant, the peel's blend of acids delivers Glutathione deep into the

basal layer where it improves cellular health, skin brightener

• Kojic Acid - antibacterial, suppresses pigment and brightens the skin

Three Boostiers:

1. Perfect PLUS PLUS

• Contains 4% Hydroquinone & 1% Hydrocortisone

• Boost the action of the peel for a stronger treatment, targets stubborn pigmentation

• Not suitable for extremely sensitive skin types

• Extra caution with Fitzpatrick skin types 4-6

2. Perfect Plus

• Boost the action of the peel for a stronger treatment

• Not suitable for extremely sensitive skin types

• Extra caution with Fitzpatrick skin types 4-6

3. Perfect Clear

• A stronger treatment for acne patients

• Boosting the action of the peel with Benzoyl Peroxide and Hydrocortisone

Helpful Reminders:

• We never apply more than two vials of any VI Peel to a patient in a 48-hour period

• Recommended treatment plan: Two to four peels per year

• A patient with stubborn acne or hyperpigmentation/melasma may benefit from a series of peels spaced four

weeks apart

• Patient should refrain from activities that will produce excessive amounts of perspiration for the first 72-96 hours

• VI Peels are safe for patients 13 and up

Perfect Derma Peel Patient Consent

Contraindications:

• Underwent any kind of surgery and not fully recovered

• Those who keloid

• Allergy to aspirin

• Uncontrolled diabetes

• Patients who are pregnant or who are breastfeeding

• Skin cancer; must be cancer free for a period of 3 years and must have direct written notice from physician, and patients who are undergoing or have undergone chemotherapy and or radiation therapy within 6 months

• Pre-existing inflammatory dermatosis (psoriasis, atopic dermatitis, pemphigus, etc.)

• History of drugs with photo-sensitizing potential or use of Accutane within the last 6 -8 months

• Inflamed, agitated skin or wart in treatment area

• Patients who have an aspirin, hydroquinone, or phenol allergy

• Active bacterial, viral, fungal infection, or open wounds

• Patients with a history of an autoimmune or liver disease/disorder, as well as any condition that may weaken their immune system

Pre-Treatment:

PRIOR OXIGEN RX OR FACIAL TREATMENT REQUIRED AT LEAST ONE MONTH PRIOR PERFECT DERMA PEEL TO IMPROVE TRANSDERMAL FUNCTION AND SKIN BARRIER.

• Avoid direct sun exposure, tanning beds, and spray tans for at least 2 weeks prior to treatment

• Avoid retinoids, glycolic acid, salicylic acid, benzoyl peroxide, AHA’s, BHA’s, and all exfoliants 2 weeks prior to treatment.

• Avoid laser hair removal, waxing, depilatory creams, threading, and cosmetic fillers two weeks prior to

treatment

• Avoid antibiotics and topical prescriptive medications 2 weeks prior to treatment

Post-Treatment:

• Mild to moderate redness and swelling may be present

• Peeling generally begins by day 2 or more commonly by day 3 and continues through day 7. Do not scrub,

pick, or pull as it may result in infection, redness, irritation, or hyperpigmentation

• Follow the post care instructions provided in the post treatment kit

I Understand That:

• There may be some degree of discomfort such as burning, stinging, redness, heat, or tightness during and after

the procedure.

• 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.

• I understand although complications are very rare, sometimes they may occur. In the event of any complications, I

will immediately contact Legacy Pain and Regenerative Medicine.

• 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.

• I understand that maintenance of treatments are necessary to maintain results.

• I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the Perfect Derma Peel by 2 weeks before and 2 weeks after the skin has completely exfoliated.

• 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.

• I understand that I must protect my skin with the aftercare products provided in the kit and avoid sun exposure

during the 7 day exfoliation process.

• I understand that this is an elective cosmetic procedure.

• 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 therapist releases me to do so.

I ATTEST TO THE FOLLOWING:

• I do not have any contraindications listed above, or I have provided written consent from my healthcare provider

allowing me to have the procedure regardless of my contraindications.

• I understand that results will vary among individuals and that although I may see a change after my first

treatment, I may require a series of sessions to obtain my desired outcome.

• I understand that there are no guaranteed results from this treatment. Many variables exist such as age, sun damage, on-going sun exposure, smoking, excessive alcohol intake, climate, diet and water intake,

skin thickness, and sensitivity.

• Regardless of precautions taken, I acknowledge the possibility of an adverse reaction to VI Peel and accept sole

responsibility for any medical care that may become necessary. I will immediately contact Medical Aesthetics Bar if there are any adverse reactions.

• I will not scratch, pick, pull at, or abrade the treated skin.

• I understand that a minimum of SPF 32-50 sun protection is required daily.

• I understand that to achieve maximum results the recommended pre/post home care routine must be followed.

• I understand that if I alter the routine or use products not recommended by the skin care professional the results

could be altered.

• The procedure and side effects have been explained to me, including alternative methods, as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and therefore there can be no guarantees as expressed or implied either as to the success or other result of the treatment. I am aware that The Perfect Derma Peel treatment is not permanent as natural degradation will occur over time if I do not keep up with skin routines and collagen