VI Peel Consent Form

The VI Peel* contains a synergistic blend of powerful ingredients which are suitable for all skin types. VI Peels will improve the tone, texture, and clarity of the skin. It will reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles, clear acneic skin conditions, and reduce or eliminate acne scars.

Contraindications

• Patients who are pregnant or breastfeeding
• Patients who have an aspirin allergy or phenol allergy
• Patients who have used isotrentinoin (Accutane*) within the past 3 months
• Patients who have active cold sores. warts, open wounds or history of herpes simplex
• Patients who are undergoing chemotherapy and/or radiation therapy
• Patients with a history of an autoimmune disease or any condition that may weaken their immune system
• Patients who have a liver condition

Please sign below or if you prefer to print this form and bring it with you then click HERE.