Enzyme treatments are gentle exfoliating processes that are designed to be less aggressive than even the mildest chemical peel, but more active than serums you can use at home. Enzyme treatments are excellent treatments for sensitive and dry skin, including acneic skin and for individuals with rosacea.
INFORMED CONSENT FOR ENZYME TREATMENT
I, ____________________________________________, give permission to my skin care professional, ____________________,
to perform the Circadia treatment: Cocoa Enzyme Raspberry Enzyme Zymase Enzyme
1. I agree to complete a Confidential Skin Health Questionnaire. I agree to complete and be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes
smoking, outdoor exposure, tanning beds, excessive alcohol consumption and/or recreational use of controlled substances, will effect and diminish the effectiveness and result of the treatment.
2. I have disclosed to my skin care professional any surgical procedures, laser treatments, or facial procedures that I have had or intend on having in the future.
3. I am not presently pregnant or lactating
4. I have not had any recent chemotherapy or radiation treatments
5. I have not recently waxed or used a depilatory (such as Nair) on the area being treated today. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters or cold sores.
6. I understand that I should not have a treatment if I intend to be in the sun or use a tanning bed and will refrain from excessive sun exposure and the use of a tanning bed while I am undergoing treatment.
7. I have disclosed to my skin care professional any treatments of any kind that I have received within 14 days of this treatment whether the treatment was performed at this location or any other location.
8. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complication, I will immediately contact the skin care professional who performed the treatment.Circadia by Dr. Pugliese, Inc. Copyright 2013.
9. I understand that the following conditions preclude me from having this treatment at this time and verify that none of these conditions apply to me at this time.
______ Allergic to citric fruits (oranges, limes, grapefruit, lemons)
______ Allergic to cocoa, chocolate, and/or raspberry
______ Allergic to pineapple and/or papaya
______ History of being “highly allergic” to anything
______ Pregnant or lactating
______ Current use of antibiotics (topical or systemic)
______ Use of Accutane® within the past 12-months
______ Laser resurfacing surgery within the last 12-weeks
______ Using glycolic acid products
______ Use of Retin-A®, Renova®, retinoids (Vitamin A) in the last 4-weeks
______ Broken Skin on areas to be treated
______ Visible inflammation or inflammatory lesions
______ Recent peels within four weeks
______ Herpes virus (cold sores) on mouth
______ Laser Hair Removal within 6 weeks
______ Currently undergoing chemotherapy or radiation treatments
10. I understand the cost of the treatment and the fee structure has been explained to me.
11. My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, or
12. I understand that my practitioner will recommend home care products to work in tandem with the in-clinic treatment. I am willing to follow recommendations by my skin care professional for home care, including a sunscreen.
13. I consent to the taking of photographs to monitor treatment effect and results if desired by my skin care professional.
In the event of any questions or concerns, I will consult my skin care professional immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks,
complications, and limitations. I will hold the skin care professional and staff harmless from any liability that may result from this treatment.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
Client Signature ________________________________________ Date __________________________
Skin Care Professional ___________________________________ Date _________________________