Skin Peel Consent Information with Additional Patient Consent for Treatment During COVID-19 Pandemic
I understand that the novel coronavirus, the World Health Organization has declared COVID-19, a
worldwide pandemic and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended.
This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.
I understand the Management and Clinical Staff are closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19.
However, given the nature of the virus, I understand there is an inherent risk of becoming infected
with COVID-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective consultation/medical treatment/procedure, and I give my express permission to proceed.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the medical consultation/ treatment/procedure itself.
I have been given the option to defer my medical consultation/treatment/procedure to a later date.
However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired medical treatment/procedure I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:
• Shortness of Breath
• Loss of Sense of Taste or Smell
• Dry Cough
• Runny Nose
• Sore Throat
I understand that air travel significantly increases my risk of contracting and transmitting the COVID19 virus. I confirm that I have not travelled in the past 15 days.
I confirm that if I develop COVID-19 symptoms following my medical
consultation/treatment/procedure or a known contact of mine develops symptoms, I will
immediately inform the practitioner to enable appropriate measures to be put in place and contact
tracing to commence I confirm I have been informed that.
I understand that further lockdown may impact on managing complications and immunological reactions.
Alumier MD – Patient Consent
Prior to receiving treatment, I have reviewed and signed the Client Profile given to me by my physician/skin care professional. I have been truthful in disclosing information that may have bearing on this procedure including the following:
• ACCUTANE USE (If so do not do treatment)
• PREGNANCY (If so do not do treatment)
• HISTROY OF COLD SORES
• ASPIRIN ALLERGY
POSSIBLE ADVERSE EVENTS:
I have been informed that the following may occur post treatment:
• Hyperpigmentation/hypopigmentation (to minimise the chance of this occuring, the proper post procedure must be followed)
• Allergic Reaction: I also understand that exposure to different ingredients found in the treatment and associated home care products may result in an allergic reaction. If an allergic reaction occurs, I will immediately discontinue use of all professional treatments and AlumierMD home care products and consult my skin care specialist.
• Contact dermatitis, inflammation (redness), edema (swelling), skin irritation (itchiness)
• Temporary sensation of heat and itchiness immediately following treatment
I understand that I may or may not actually peel and that each treatment is individual. I understand that the degree of peeling does not correlate with the degree of improvement.
CONDITIONS OF TREATMENT:
I agree to refrain from the following activities for 14 days post treatment:
• Sun or tanning bed exposure – Microdermabrasion – Laser hair removal – Photofacials – Chemical peels – Laser / RF skin treatments
I agree to refrain from the following activities for 7 days post treatment:
• Waxing, threading, and all use of other depilatories – Neurotoxin injections (e.g. Botox,Dysport)
• Dermal filler injections – Use of retinoids – Use of mechanical exfoliants
• Use of topical AHA/BHA and all other exfoliant topical skin care products
• Use of sunless tanning products – Acne topical treatments
I agree to disclose the names of all prescription and non-prescription products that I am using.
I agree to follow all post-procedure protocols recommended by my skin care professional.
I agree to use a professional, broad spectrum sun protection product (SPF 30 or higher) for a minimum of 14 days post treatment.
LIMITATIONS TO TREATMENT:
I understand there are no guarantees as to the results of this treatment due to many variables including age, skin conditions, sun damage, smoking, climate, etc. I understand that this treatment is cosmetic and that no medical claims are expressed or implied. I understand that to achieve maximum results, I may require several treatments.
I understand that although complications are rare, they do occur and prompt treatment is necessary. In the event of a complication, I will contact the physician/skin care professional who performed my treatment. I hereby certify that all the information that I have provided has been accurate and truthful. I acknowledge the above adverse events, limitations and complications. I further acknowledge that these adverse events, conditions, limitations and complications have been explained and that I accept and consent to treatment. I agree to follow all post treatment care instructions provided to me. I acknowledge that I have been provided with adequate time to read, understand and accept the above adverse events, limitations and complications.
PRE & POST CARE INSTRUCTIONS
PREPARATION FOR A PEEL TREATMENT
You will be having a skin treatment on the day of your appointment. Please follow the instructions below to prepare:
• Use of AlumierMD home care products prior to your peel are recommended to prepare the skin, allow for better treatment results and reduce the risk of complications. Please consult your physician or skin care professional for appropriate recommendations for your skin type and condition
It is recommended that you take the following into
• For best results and to reduce the risk of complications, it is recommended that you use AlumierMD home care products for 10 to 14 days prior to treatment
• If you are lactating, pregnant, or may be pregnant, consult your physician before receiving any treatment
• Avoid sun exposure and tanning beds for at least two weeks prior to treatment
• Avoid the use of retinoid products (eg. retinol, Retin-A®, Tazorac®) and high levels of AHA and BHA products for approximately 7 days prior to the treatment. Consult your doctor before temporarily discontinuing the use of any prescription medications
AlumierMD skin treatments result in minimal to no downtime but create dramatic and visible results. Treatments can cause slight redness, tightness, peeling, flaking or temporary dryness. Most clients do not find it necessary to apply makeup, as the skin with be smooth, dewy and radiant following your treatment.
POST SKIN PEEL TREATMENT TIPS
You have just received an AlumierMD Skin Treatment. Due to the nature of these treatments, you should not necessarily expect to ‘peel’. However, you may have light to moderate flaking in a few localised areas for 3 to 7 days. You may also experience residual redness, which lasts in most clients from 1 to 12 hours. It is recommended that you do not apply makeup the day of the treatment. It is ideal to allow the skin to stabilise and rest overnight. However, makeup can be applied, if necessary.
Tonight, your skin will feel tight and ‘pulled’. Although you may or may not actually ‘peel’, it is likely that you will experience light ‘exfoliation’. It may take 2 or more treatments to target the deeper layers of skin to loosen and ‘peel’. In order to obtain maximum results and avoid complications, please follow the post-peel instructions listed below for approximately 5 to 7 days:
AVOID DIRECT SUN EXPOSURE AND EXCESSIVE HEAT.
Only use the following skin care products for 5 to 7 days post treatment.
Step 1: SensiCalm Cleanser
Step 2: Recovery Balm
Step 3: Sheer Hydration Broad Spectrum SPF 40 Sunscreen
Step 1: SensiCalm Cleanser
Step 2: Recovery Balm
Discontinue use of any product that irritates your skin and contact your skin care professional.
IMPORTANT: Keep your skin hydrated. Hydration is key to proper healing.
DO NOT cleanse your skin in the evening of your peel or treatment
DO NOT pick or pull any flaking skin
DO NOT tan or use a tanning booth for at least 14 days post peel.
DO NOT have electrolysis, waxing, threading or any other form of hair removal for 7 days post treatment
DO NOT use facial scrubs or mechanical forms of exfoliation for 14 days post peel
DO NOT use retinoic acid, AHA or BHA for 14 days post peel.
DO NOT have laser hair removal, photofacials, chemical peels or microdermabrasion for 14 days post peel.
DO NOT apply ice or ice water on the treated area
DO NOT use hot tubs, steam rooms, saunas, and/or excessively hot showers for 2 days post peel.
DO NOT go swimming for 2 days post peel
DO NOT participate in aerobic exercise for 2 days post peel.
For questions or concerns, please call your skin care specialist:
* In case of emergency such as allergic reaction, please proceed to the nearest emergency room