Chemical Peel Consent

Chemical Peel CONSENT

INFORMED CONSENT FOR CHEMICAL PEEL PROCEDURES

This informed consent confirms that I have been satisfactorily informed and educated regarding chemical peel procedures, including their purpose, mechanism of action, expected benefits, alternatives, limitations, risks, and possible complications. I acknowledge that I have received adequate information to make a voluntary and informed decision to proceed with treatment.

Nature of Chemical Peels

I understand that a chemical peel is a skin rejuvenation procedure designed to improve the appearance and quality of the skin by promoting controlled exfoliation and regeneration.

I understand that, depending on the type and depth of the peel used, chemical peels may be utilized to address concerns including, but not limited to:

  • Aging skin and fine lines
  • Wrinkles (rhytids)
  • Hyperpigmentation and melasma
  • Acne and acne scarring
  • Uneven texture or tone

Procedure Description

I understand that the procedure involves the application of a chemical solution to the skin, which causes exfoliation and eventual peeling of the treated layers.

I understand that results are not immediate, and visible improvement occurs gradually as the skin heals and regenerates.

Treatment Intensity Selection

I understand that chemical peel treatments may vary in intensity. More aggressive treatments may result in increased peeling, redness, swelling, and longer recovery time but may achieve greater improvement with fewer sessions. Less aggressive treatments may involve milder peeling, reduced downtime, and may require multiple sessions to achieve desired results. I understand that treatment intensity will be selected based on my skin condition, goals, and provider judgment.

Treatment Series & Maintenance

I understand that although improvement may be seen after the first treatment, multiple sessions may be required to achieve optimal results depending on the severity of my skin condition and treatment goals.

I understand that maintenance treatments may be necessary due to ongoing skin aging, environmental exposure, and individual skin biology.

Expected Results & Variability

I understand that results vary between individuals and that it is not possible to predict how I will respond or how many treatments may be required.

I understand that medicine is not an exact science, and no specific outcome or degree of improvement can be guaranteed, either expressed or implied.

I understand that I am paying for professional services, not for a guaranteed cosmetic result.

Alternatives to Treatment

I understand that alternatives may include topical skincare, oral medications, injectable treatments, energy-based devices, surgical options, or no treatment, and that I have discussed these alternatives with my provider.

Medical History & Disclosure

I agree to disclose all medical conditions, allergies, and current medications, including supplements.

I understand that chemical peels may trigger cold sore or herpes simplex outbreaks and have informed my provider if applicable. I understand that prophylactic medication may be recommended.

I will notify my provider if I am taking medications that increase photosensitivity, have used Accutane (isotretinoin) within the past six months, have a history of psoriasis, eczema, dermatitis, or rosacea, or have used Retin-A, Renova, prescription skincare, vitamin C, bleaching agents, or acid-based products within the past forty-eight hours.

I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of chemical peels during pregnancy and breastfeeding has not been established. If uncertain, I will request pregnancy testing prior to treatment.

Risks & Possible Complications

I understand that chemical peels involve risks, which may include but are not limited to:

  • Discomfort or burning sensation during treatment
  • Swelling or tenderness
  • Redness (erythema) or petechiae
  • Pigment changes, temporary or rarely permanent hypo- or hyperpigmentation
  • Blistering, crusting, scabbing, or flaking
  • Milia, pustules, or infection (rare)
  • Prolonged skin sensitivity
  • Scarring (rare)
  • Allergic reactions
  • Unknown or unforeseen side effects

Delayed Reactions & Patient Responsibility

I understand that individual responses vary, and delayed reactions may occur.

I agree to promptly notify AI Wellness Center of Excellence if I experience any unusual, worsening, or concerning symptoms and to allow the clinic the opportunity to evaluate and participate in my care.

Post-Treatment Compliance

I agree to follow all post-procedure instructions carefully, including sun avoidance, skincare use, and activity restrictions, to reduce the risk of complications and optimize results.

Authorization & Provider Qualifications

I hereby authorize Dr. Gideon Kwok, D.O., and/or trained and qualified licensed medical providers acting within their scope of practice to perform chemical peel procedures on me.

I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider administering my treatment and that I am satisfied.

I affirm that my consent is voluntary, informed, and freely given.

Final Acknowledgment

By proceeding with treatment, I certify that I have read and fully understand this consent form, that all disclosures have been explained to me, that I have had the opportunity to ask questions, that this consent supersedes any prior verbal or written disclosures, and that I freely consent to chemical peel procedures.