Glothera informed consent1.doc
INFORMED CONSENT FOR CHEMICAL EXFOLIATION TREATMENT
Please read and initial after each paragraph.
I have been given the Skin Care History Questionnaire and have read and answered the questions thoroughly.
I have discussed any further questions and or concerns that I may have with my Skin Care Specialist.
My Skin Care Specialist has answered any questions I have regarding my post care. I acknowledge my obligations to closely follow the post care instructions and visit my Skin Care Specialist for a post treatment as specified.
I am aware and acknowledge that there is a rare possibility of an allergic reaction. I have discussed thoroughly with my Skin Care Specialist any such reactions and understand
I have had a patch test and it is negative. In the event of any complications, I will immediately contact my Skin Care Specialist who performed the treatment.
I am willing to forego a patch but understand there could be an allergic response.
I have been advised that my treatment is a noninvasive, light exfoliation consisting of singly, or a combination of Salicylic Acid, Lactic Acid, Glycolic Acid, Resorcinol, Trichlorocetic Acid, Retinolic Acid and Enzymes.
The use of the above ingredients stimulates the skin to generate new skin cells. It does not replace deep chemical peels, laser resurfacing or plastic surgery.
I acknowledge that there may be some degree of discomfort during application. I will notice a warm sensation and the skin may tingle, sting, pin pricking, heat (burn) or tightness. Immediately after the chemical exfoliation treatment, my face may appear frosted or red, and by day two (2), the skin may darken in color, feel tighter, and be more
sensitive. Days two (2) through seven (7), the skin may exfoliate. I am not to pick or peel skin. Pulling or picking skin may lead to infection, hyperpigmentation and or surface scars. I may experience some breaking out after a treatment.
I acknowledge that I will avoid direct sun exposure during this procedure and will apply a sunscreen daily.
Chemical Exfoliation treatments may lighten hyperpigmented skin, reduce acne breakouts
or diminish fine lines. I acknowledge that there is NO GUARANTEED
result. I am aware that
there could even be an increase of uneven color from this procedure.
I acknowledge that I have not been using Accutane, Differin®, Azelex®, Finacea™, Tazorac® or any other prescribed medication(s) for the past two weeks.
I acknowledge that if I am prone to cold sores (Herpes Simplex), I may need a prescription for Denavir®, Zovirax® or Abreva from my Physician prior to having a chemical exfoliation treatment. I am aware the treatment could bring about cold sores.
I acknowledge that I am not aspirin sensitive. If I am aspirin sensitive, I have discussed this with my Skin Care Specialist and understand there could be a reaction.
I acknowledge that to achieve maximum results, I may need several treatments and use home care products.
I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.
I acknowledge that there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, hormones, lifestyle, climate, etc. I understand I may or may not actually peel, and that each case is
I hereby agree to all of the above and agree to have this treatment be performed on me.
I further agree to follow all post -peel care instructions as I am directed.
Universitätsklinikum Heidelberg Fachweiterbildung zur Pflege und Betreuung des Tumorpatienten und schwerst-chronisch Kranken Nachqualifizierungsseminar im Rahmen der DKG-Empfehlungen „Pflege in der Onkologie“ § 23 Abs. 6 Nr. 2 Die Pflege in der pädiatrischen Onkologie im Wandel der Zeit Ruthild Korn Faberstraße 50 67063 Ludwigshafen Stellvertretende Stationsleitung
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