VI Peel Informed Consent Form


 

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

Post-Treatment Care Instructions

Day of Treatment:

  • Leave peel solution on for 4 hours (6 hours for VI Peel Precision Plus)
  • Wash gently with lukewarm water and provided cleanser
  • Apply provided post-peel protectant

Days 1-7:

  • Cleanse gently twice daily
  • Apply provided towelettes as directed (typically days 1-4)
  • Apply post-peel protectant frequently
  • DO NOT pick, peel, or rub off flaking skin
  • Avoid excessive sweating, sun exposure, and swimming
  • Use SPF 30+ sunscreen when outdoors

After Peeling is Complete:

  • Continue using gentle skincare products for 2 weeks
  • May gradually resume normal skincare routine
  • Maintain strict sun protection
  • Wait 4-6 weeks before next peel treatment

Consent Statements

Please initial each statement:

1. I understand the nature of VI Peel® treatment and the expected healing process.

2. I have disclosed all relevant medical history, allergies, and current medications.

3. I understand the potential risks and side effects of chemical peeling.

4. I agree to follow all pre-treatment and post-treatment instructions.

5. I understand that I must NOT pick or peel my skin during the healing process.

6. I understand the importance of sun protection and agree to use SPF 30+ daily.

7. I understand that results may vary and multiple treatments may be needed.

Signatures

Patient Signature: _________________________ Date:

Provider Name: Date:

ENNU Aesthetics - VI Peel® Services

Form Version: 2025.01

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Tabitha Herron
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Carrie Emerson
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Carrie Emerson
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Evelyn Silverthorn
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Evelyn Silverthorn
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Signature Certificate
Document name: VI Peel Informed Consent Form
lock iconUnique Document ID: 4ced72c5ac662068cb74a9faf9887db96f6314e3
Tabitha Herron
Party ID: f02c43d6-0230-40df-a337-44ad58f81c9d
Awaiting signature
Carrie Emerson
Party ID: e6fd72d4-4008-4f21-aee7-d344d0575cbe
Awaiting signature
Evelyn Silverthorn
Party ID: 6e8d69f9-aa3c-492a-95ed-1f739117f3b2
Awaiting signature
Timestamp Audit
January 11, 2026 2:19 am EDTVI Peel Informed Consent Form Uploaded by ENNU Patient Docs - ennu-appointments@ennu.co IP 24.238.5.27
January 15, 2026 10:38 am EDT{"user_id":979,"email":"patti.beard125@gmail.com","appointment_id":"10834","assigned_by":"retroactive_script"}
February 4, 2026 10:59 pm EDTDocument viewed by Tabitha Herron - tdlherron@aol.com IP 24.238.5.27
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