Chemical Peel Consent

  • I agree to the following information regarding the use of the Theraderm Chemical Peel Products:
    1. l will follow the Theraderm Recommended Protocol for performing chemical peels.
    2. l am aware it is absolutely necessary to neutralize all AHA acid peels with Sodium Bicarbonate: this pertains to both the Theraderm 70% and 50% Lactic Acid peel solutions, l acknowledge that water will dilute the peel, but not effectively neutralize the acid.
    3. l am aware of Theraderm’s recommendation to use the Theraderm Prepare Pre-Procedure System and Theraderm Prolong Post-Procedure System.
    4. l will provide my patient/client with an informed consent form and will obtain their approval to proceed with the chemical peel procedure.
    5. l will provide Theraderm with a current copy of my state license, upon request.

  • I confirm that under our state law, I am licensed to conduct chemical peels checked below.