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VI Peel Consent

Please fill out the form below. If you have any difficulty filling it out online, you may click below to download the PDF form. After completing the form, please email it over to info@altitudedentalfl.com.

Pre-Treatment Details

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Prior to receiving treatment, I have informed the practitioner of any conditions or medications that may contraindicate this statement.
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I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during the procedure and for the following week.
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I understand that there is no guarantee regarding final results of the peel. Though uncommon, hyperpigmentation may develop, which may persist for weeks or months after the peel.
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I understand that although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the practitioner who performed the treatment.
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I understand that maintenance VI Peel* treatments are necessary to maintain results, as well as the recommended Vl Derm* skin care regimen.
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I understand that extended direct sun exposure, including tanning beds, is strictly prohibited before and after receiving the VI Peel*.
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I understand that I must protect my skin with VI Derm SPF 50+ and avoid sun exposure during the exfoliation process.
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I understand that this is an elective cosmetic procedure and is non-refundable. I understand payment is my sole responsibility.
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I understand that no other chemical peels or medical device treatments may be performed on my skin until my physician/clinician releases me to do so.
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I understand that I must avoid strenuous exercise and heavy sweating, which will raise my skin temperature, for at least 72 hours following the peel.
Date
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Print Name*
Signature

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Fax: 772-569-6313
Email: info@altitudedental.com
1625 20th St Vero Beach, FL 32960
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