Pro Power Peel Consent Form Name First Last PhoneDate MM slash DD slash YYYY This treatment is designed to resurface the skin. You may experience temporary burning, itching, or stinging. Please inform your professional skin therapist if you experience these sensations. Your full participation during and after the treatment will determine the outcome. It is important that you strictly adhere to the homecare products and regimen that your professional skin therapist has recommended. It is possible to have a poor reaction or less-than-expected improvement of the skin. No guarantee is made or implied as to the precise results, peeling times or discomfort. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks? Yes No Do you have active cold sores? Yes No Have you received Botox or other injectable procedures within the past week? Yes No Do you sunbathe or use tanning beds? Yes No Do you experience redness, itching, or stinging on your skin? Yes No Consent I agreeI release and waive any claims against Dermalogica, LLC and PSH Wellness and their affiliates and subsidiaries, and their respective officers, directors, agents, servants and employees, for any liability, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Pro Power Peel treatment, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Dermalogica and/or PSH Wellness. I have received Post-Care instructional sheet. Signature
