Chemical Peel Consent Form

Declaraciones con iniciales

1. I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and desire to receive the chemical peel procedure.
2. I have been informed of the nature, risks, and possible complications and consequences of a chemical peel. I understand the chemical peel procedure may have known or unknown complications including but not limited to: infection, scarring, inconsistent color, and allergic reaction.
3. I give permission to "JM STUDIO & SPA LLC / Joselin Ortega" to perform the chemical peel treatment on me.
4. I request the chemical peel procedure and accept the permanence of the procedure as well as the possible complications and consequences of said procedure.
5. Choose one: I consent _____ (initial) or waive _____ (initial) the patch test.
6. I understand I must discontinue all oral and topical medications used at least 14 days prior and 14 days post procedure and should consult my physician before discontinuing use for the chemical peel procedure.
7. I have received pre- and post care instructions and I will strictly adhere to such instructions. I understand that my failure to properly follow pre and post care instructions may compromise my procedure.
8. I understand this procedure may be uncomfortable or slightly painful while being performed.

Acuerdo final

I consent to allow “Joselin Ortega / JM STUDIO & SPA LLC” to consult with and evaluate me in order to determine if I am a good candidate for a chemical peel. I understand that photographs and measurements will be taken and kept in my file. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities. I understand the contraindications and possible side effects of chemical peels as discussed with "Joselin Ortega / JM STUDIO & SPA LLC". Furthermore, I agree to waive all liabilities toward "Joselin Ortega / JM STUDIO & SPA LLC" for any injury or damages incurred due to my misrepresentation of my health history.

• Signature.
• Date.