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
ENNU Aesthetics - VI Peel® Services
Form Version: 2025.01
Form Complete
