patient profile Lifestyle: Are you pregnant or lactating? Name: DOB: Age: Sex: Address: City: State: Zip: Phone:
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- Gwendoline McDaniel
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1 patient profile Name: DOB: Age: Sex: Address: City: State: Zip: Phone: About you: What is your hereditary background? (note all that apply) Nordic / Scandinavian / Irish / English / Asian / Mediterranean / Hispanic / Native American / Middle Eastern / African American / Other Natural eye color: Natural hair color: Do you consider your skin (note the best option): Sensitive / Resilient / Unsure Describe your skin (note all the apply): Normal / Dry / T-Zone/Combination / Thick / Thin / Saggy /Firm / Oily / Acne / Comedones/Blackheads / Milia / Cysts / Breakouts / Acne-scarred / Large pores /Small pores / Rosacea / Eczema / Freckled / Sun-damaged / Melasma / Hyperpigmentation / Hypopigmentation / Uneven/Blotchy / Mature / Wrinkled / Patchy dryness / Sallow / Psoriasis / Dehydrated/Lacking moisture / Asphyxiated / Telangiectasia/Broken surface capillaries What are the changes you d most like to see in your skin? Lifestyle: Are you pregnant or lactating? (Please consult with your obstetrician. Only the Oxygenating Trio, Detox Gel Deep Pore Treatment or Hydrate: Therapeutic Oat Milk Mask are appropriate.) Do you wear contact lenses? (Remove contacts if eyes are sensitive or if having microdermabrasion.) Do you currently have a sunburned/windburned/red face? Why? Are you in the habit of going to tanning booths? (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.) Do you participate in vigorous aerobic activity or sports? What type? Do you smoke or use tobacco? What kind of work do you do? On average, how many hours per week do you spend outdoors? v30_
2 Medical/treatment history: Do you currently use depilatories or wax? (Discontinue use five days pre- and post-treatment.) Have you had a chemical peel or any type of procedure with a medical device? Within the last 14 days? What type? Do you have regular collagen, Botox or other dermal filler injections? (Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) Have you recently had laser resurfacing or facial surgery? Describe: When? Are you currently taking any medications, topical or otherwise? (Tretinoin/Retin-A /Renova /Differin /Tazorac /Avage / EpiDuo /Ziana ) Which one(s)? For how long? What strength? (High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment. Consult your physician before discontinuing use of any prescription.) Have you ever undergone Accutane therapy (isotretinoin)? (If you are currently using Accutane therapy (isotretinoin), please consult with your dispensing physician.) (If you are no longer using Accutane therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel I, Sensi Peel, Ultra Peel II, Esthetique Peel, Oxygenating Trio, Hydrate: Therapeutic Oat Milk Mask or Revitalize: Therapeutic Papaya Mask.) Do you develop cold sores/fever blisters? Last breakout? Are you allergic/sensitive to (note all that apply) milk / apples / citrus / grapes / aloe vera / aspirin / perfumes / latex / hydroquinone / mushrooms? If any other allergies, what? Have you ever used any other products that caused a bad reaction?describe: v30_ Patient signature: Date: Clinician signature: Date:
3 18 patient consultation consent form B Continued Treatment Consent Date Initials Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as: tretinoin, Retin-A, isotretinoin, Accutane, Differin, Tazorac, Avage, EpiDuo or Ziana. I understand there may be some degree of discomfort such as stinging, pin-prickling sensation, heat or tightness. I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc. I understand I may or may not actually peel and that each case is individual. I understand that the amount of peeling does not correlate with degree of improvement. I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximum results, I may need several treatments. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the physician/clinician who performed the treatment. I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment, and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging. I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum SPF of 30 is mandatory. I have not had any other chemical peel of any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location. I understand that I should follow my clinician s recommendations for post-procedure skin care to minimize side effects and maximize results. I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-peel care instructions as I am directed. Signature: Date: Initials: Signature of Clinician: Signature of Witness: Please print out the completed form and bring to your appointment!
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6 20 patient consultation preparation for a peel treatment B You will be having a light peel treatment on the day of your appointment. Please follow the outline below to prepare. n Use of PCA SKIN daily care products prior to your peel will prepare the skin, allow for better treatment results and reduce the risk of complications. This is recommended but not mandatory. Please consult your physician or skin care clinician for appropriate recommendations for your skin type and condition. It is recommended that you take the following into consideration: n For best results and to reduce the risk of complications, it is recommended that you use PCA SKIN daily care products 10 to 14 days prior to treatment. n If you are lactating, pregnant or may be pregnant, only an Oxygenating Trio, Detox Gel Deep Pore Treatment or Hydrate: Therapeutic Oat Milk Mask is appropriate. Consult your OB/GYN before receiving any treatment. n Do not go to a tanning bed two weeks prior to treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging. n It is recommended that extended sun exposure be avoided, especially in the 10 days prior to treatment. n It is recommended to delay use of tretinoin, Retin-A, Renova, Differin, Tazorac, Avage, EpiDuo, Ziana and high-percentage AHA and BHA products for approximately five days prior to treatment. Consult your physician before temporarily discontinuing use of any prescription medications. PCA SKIN superficial peels result in little to no downtime but create dramatic and visible results. Treatments may cause slight redness, tightness, peeling, flaking or temporary dryness. Most patients find it unnecessary to apply makeup, as the skin will be smooth, dewy and radiant following your treatment. If you would like to apply makeup, allow approximately 15 minutes for the ph of the skin to stabilize before applying foundation
7 patient consultation 23 post-procedure skin treatment tips for two days post-procedure: B n Stay cool! Heating internally can cause hyperpigmentation. n Do not put the treated area directly into a hot shower spray. n Do not use hot tubs, steam rooms or saunas. n Do not go swimming. n Do not participate in activities that would cause excessive perspiration. n Do not use loofahs or other means of mechanical exfoliation. n Do not direct a hair dryer onto the treated area. n Do not apply ice or ice water to the treated area. general guidelines: n After receiving a PCA SKIN professional treatment, you should not necessarily expect to peel. However, light flaking in a few localized areas for several days is typical. Most patients who undergo these treatments have residual redness for approximately one to 12 hours post-procedure. n As with all peels and treatments, it is recommended that makeup not be applied the day of treatment, as it is ideal to allow the skin to stabilize and rest overnight; however, makeup may be applied 15 minutes after the treatment if desired. n To minimize side effects and maximize results use the Post-Procedure Solution for three to five days or until flaking has resolved. n If the skin feels tight, apply ReBalance for normal to oily skin types or Silkcoat Balm for drier skin types to moisturize as needed. For maximum hydration, you can apply Hydrating Serum under ReBalance or Silkcoat Balm. n Moisturizer should be applied at least twice a day, but can be applied more frequently for hydration and to decrease the appearance of flaking. n It is recommended that other topical, over-the-counter medications or alpha hydroxy acid products not be applied to the skin seven days post-procedure, as they may cause irritation. n It is recommended to delay use of tretinoin, Retin-A, Differin, Renova, Tazorac, Avage, EpiDuo or Ziana five days post-procedure. Consult your physician before temporarily discontinuing use of any prescription medications. n Avoid direct sun exposure and excessive heat. Use Weightless Protection Broad Spectrum SPF 45, Perfecting Protection Broad Spectrum SPF 30, Protecting Hydrator Broad Spectrum SPF 30 or Hydrator Plus Broad Spectrum SPF 30 for broad spectrum UV protection. n Do not go to a tanning bed for at least two weeks post-procedure. This practice should be discontinued due to the increased risk of skin cancer and signs of aging. n Do not pick or pull on any loosening or peeling skin. This could potentially cause hyperpigmentation. n Do not have electrolysis, facial waxing or use depilatories for approximately five days. Do not have another treatment until your clinician advises you to do so. Products highlighted in gray denote PCA SKIN Foundational Products
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