VI Peel Informed Consent

VI Peel® Informed Consent Form

(Aesthetics)

Date:

Patient Information

Patient Name: {{patient_first_name}} {{patient_last_name}}
Date of Birth: {{patient_birthdate}}
Email: {{patient_email}}

Peel Selection

Please indicate which VI Peel formulation you are receiving:

VI Peel Original - Anti-aging, fine lines, wrinkles

VI Peel Precision - Enhanced anti-aging

VI Peel Precision Plus - Pigmentation, melasma

VI Peel Purify - Acne, oily skin

VI Peel Purify with Precision Plus - Acne with discoloration

VI Peel Advanced - Age spots, aging skin

About VI Peel®

VI Peel® is a medium-depth chemical peel that contains a synergistic blend of powerful ingredients including TCA, Retinoic Acid, Salicylic Acid, Phenol, and Vitamin C. It is designed to improve skin tone and texture, reduce age spots, hyperpigmentation, and acne scars, stimulate collagen production, and reduce fine lines and wrinkles.

Treatment Benefits:

Improves skin tone and texture
Reduces appearance of fine lines and wrinkles
Treats hyperpigmentation and melasma
Clears acne skin conditions
Stimulates collagen production
Minimal downtime (typically 5-7 days of peeling)

Contraindications

VI Peel® should NOT be performed if you have any of the following:

Allergy to aspirin or salicylates
Allergy to any VI Peel® ingredients
Active cold sores or herpes simplex virus (must be pre-treated with antiviral)
Open wounds, cuts, or abrasions in treatment area
Active eczema, psoriasis, or dermatitis in treatment area
Currently pregnant or breastfeeding
Use of Accutane within the past 6-12 months
Recent facial surgery or ablative procedures (within 6 weeks)
Active skin infections
History of keloid scarring

Pre-Treatment Questions

Have you experienced cold sores or fever blisters in the past?

Yes - I require antiviral pre-treatment

Are you currently using or have recently used any of the following?

Retinoids/Retin-A (stop 5-7 days before)

Hydroquinone (stop 2 weeks before)

AHA/BHA acids or chemical exfoliants (stop 5-7 days before)

Accutane (within past 6-12 months)

Risks and Side Effects

The following are potential risks and side effects of VI Peel®:

Expected: Peeling, flaking (typically days 3-7), temporary tightness
Common: Redness, mild discomfort, dryness, temporary darkening before peeling
Less Common: Hyperpigmentation, hypopigmentation, prolonged redness
Rare: Infection, scarring, allergic reaction, herpes outbreak