Chemical Peel Procedure Consent
A chemical peel is used to treat wrinkles, age spots, scarring, acne scarring, dyspigmentation, and other skin conditions. The procedure may require multiple sequential treatments.
Following your treatment, you may experience pain, swelling and redness, similar to a mild-sunburn, for the first several days. Light or heavy peeling of the skin may also occur.
Risks of this procedure include, but are not limited to, the following:
Pain – Some people may feel some pain with this treatment. Stinging or sharp pain may be present after the procedure and throughout the healing process.
Redness – Laser treatment will cause redness of the area. The redness may be present for weeks to months.
Swelling – Swelling will be present after the procedure and should likely resolve after 1-2 weeks.
Pigmentary Changes – The treated area may heal with altered pigmentation (either lighter or darker skin). This occurs most often with darker colored skin and after exposure of the area to sun. You may have experienced this type of reaction before and noticed it with minor cuts or abrasions. The treated area must be protected from exposure to the sun (sunscreen for 4 weeks after treatment) to minimize the possibility of such changes, although pigmentary changes may occur despite sunavoidance. While these pigmentary changes usually fade in three to six months, in some cases, the pigment change is permanent.
Alert us immediately if you have been in the sun, have had a tan, or a sunburn, within the last 4 weeks.
Scarring – There is a risk of scarring with this procedure at any time during the healing process. The scarring may be discolored and may be permanent.
Bleeding – You may experience some pinpoint bleeding which will probably stop within a few minutes without any lasting effect. The bleeding may not reach the upper level of the skin and may result in a dark reddening of the skin. The red color will darken to purple and purple-yellow and will disappear in one to two weeks. You may continue to have some oozing and bleeding for 1-3 days after the procedure.
Blistering – The chemical peel may result in blister formation. The blisters should go away within two to four days. Scarring or discoloration may result from any blister formation.
Scabbing – A scab may be present after a blister forms. The scabbing will disappear during the natural wound healing process of the skin. Scarring or discoloration may result from any scab formation.
Infection – An infection of the wound is always possible. Any blistering or bleeding must be dressed with an antibiotic ointment and covered. Any infection could last seven to ten days and could lead to scarring.
Failure to Achieve Desired Results – It is very possible that this procedure may fail to achieve your desired results. Strict adherence to the pre-op and post-op instructions is essential. You may need to repeat your treatments to achieve the desired results.
I, the undersigned, have read and understand the information contained within this consent form. My signature indicates that I have read and understand the information in the consent. I hereby release the dermatology office and my physician from all liability associated with this procedure. Furthermore, my signature below indicates my consent to the treatment described and my agreement to comply with the requirements placed on me by this consent form.
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