Jan Marini Skin Research® Informed Consent
Jan Marini Skin Research professional protocols are excellent in providing overall skin rejuvenation and can improve the appearance of fine lines and wrinkles, acne, acne scarring, sun damage and hyperpigmentation. I understand that individual results will vary and multiple peels may be necessary to achieve maximum results. A guarantee cannot be made about the degree of improvement.
I have been advised that my peel can consist of any of the following: glycolic acid, mandelic acid, salicylic acid, lactic acid, citric acid, resorcinol or retinol.
I have discussed any pre-existing medical conditions and contraindications with my physician.
I have been informed of the contraindications and possible complications by my skin care therapist and/or physician. I have been given the opportunity to discuss any additional concerns and questions and my questions have been answered to my satisfaction.
To the best of my knowledge I am not:
Prone to cold sores/fever blisters
Allergic to aspirin
Taking or have taken Accutane in the past 12 months
Currently pregnant or breast feeding
In the past week I have not received any of the following procedures:
Chemical Peel/Skin Service
Laser Hair Removal
I will take extra precautions to avoid sun exposure after my peel and wear sun protection.
I understand skin peeling can occur, however, lack of peeling is not an indication that the peel was unsuccessful. If skin peeling occurs, I am not to pick the peeling skin as to avoid scarring or infection.
By my signature below, I acknowledge that I have read this Informed Consent and understand it. I acknowledge that I have fully disclosed all necessary information when filing out the Skin & Health Questionnaire and I will inform my skin care therapist or physician of any changes. I acknowledge that I understand and will follow all pre-/post-care recommendations, including, but not limited to use of skin care products as home care to enhance results and minimize side effects, such as daily application and reapplication as needed of a broad spectrum SPF 30+. I have been adequately informed of the risks and benefits of the peel and would like to proceed with the Jan Marini Skin Research peel.
Signature of Patient
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