Informed Consent for Chemical Peeling

I authorize_______ to perform_________ on my__________

for rejuvenation of my skin treatment of pigmented lesions, acne scars and / or
wrinkles.

I understand that the procedure is purely elective, that the result may vary with each
individual and multiple treatments may be necessary.
I understand that:
1. Serious complication is rare but possible.
2. Common side effects included temporary redness and mild sunburn like the
effects that may last 3-hours or longer.
3. Pigment changes, including hypopigmentation (lightening of the skin) or
Hyperpigmentation (darkening of the skin) lasting for 1-6 months or longer may
occur.
4. Other potential risks include crusting, itching, pain, burns, infection, scabbing,
swelling and failure to achieve the desired result.
5. I understand that the sun or tanning lamp exposure and not adhering to post-
care instructions provided to me may increase my chance of complications.

I consent to photographing and/or recording of my lesions and treated area provided

my identity in not revealed by the pictures or descriptive text accompanying them.
Before and after treatment instructions have been discussed with me. The procedures
as well as potential benefits and risks have been explained to my satisfaction. I have all
my question answered. I freely consent to the proposed treatment.

Patient name & signature:

Doctor name & signature:
Witness name & signature: