Please answer the following questions.

Yes

No

1. Do you currently have an infection in the area you would like to treat?

Y

N

2. Do you have known allergies or sensitivity to chemical peel ingredients?

Y

N

3. Do you currently have open wound or cuts in the area you would like to treat?

Y

N

4.   Are you currently on isotretinoin (Accutaine)?

Y

N

5. Have you been on isotretinoin (Accutaine) within the last 6 months?

Y

N

6. Are you currently pregnant or breastfeeding?

Y

N

7. Do you have a history of keloid scar formation?

Y

N

8. Do you have a history of poor wound healing?

Y

N

9. Do you have diabetes?

Y

N

10. Are you currently using steroid containing medication?

Y

N

11. Are you currently using creams/ointment with retinoids or hydroxy acids? (tretinoin, adapalene)

Y

N

12. Do you have sensitive skin?

Y

N

13. Do you have psoriasis?

Y

N

14. Do you have atopic dermatitis?

Y

N

15. Do you have any connective tissue diseases?

Y

N

16. Have you had recent facial x-rays?

Y

N

17. Have you had recent facial surgery?

Y

N

18. Are you a smoker?

Y

N

19. Do you currently have cold sores or shingles?

Y

N

20. Do you often get cold sores or shingles?

Y

N

Risks and side effects:

I understand that the following risks and side effects may occur:

Y

N

               Redness and irritation

               Peeling and flaking of skin

               Temporary or permanent changes to skin pigmentation

               Sensitivity to sunlight

               Infection or scarring (rare)

Precautions and aftercare:

Y

N

I agree to follow all pre-treatment and post-treatment instructions provided by the doctor, including but not limited to:

               Avoiding sun exposure and using sunscreen.

               Using recommended skin care products.

               Not picking or scratching treated skin.

Alternative treatments:

I understand that alternative treatments may exist such as microdermabrasion.

Y

N