Skin Tone Enhancement System Consent (with Hydroquinone 4%)

Skin Tone Enhancement System Consent (with Hydroquinone 4%)
The pads must be used in the prescribed fashion according to the written instructions and descriptions given to me. I understand that I will experience varying degrees of the following symptoms: Dryness - Redness - Exfoliation/Peeling - Itching - Sensitive Skin - Burning - Wrinkles May Look Worse - Acne May Look Worse These symptoms will lessen and eventually subside as my skin builds tolerance.
Initial*
I agree to continue with the use of the Skin Deep Skin Tone Enhancement System as directed. Doing so will help with my safety and provide adjustments towards maximizing results.
Initial*
I understand the best results are achieved with adherence to the program over several weeks and/or months.
Initial*
I understand that excessive application of the products or picking, rubbing the skin can cause a great deal of discomfort and even blistering, especially in the early weeks of treatment. If any reactions are initiated to the point of skin breakdown or infection, I will contact the office immediately. Careless inattention to such reactions may result in complications such as infection, injury, discoloration, or possible superficial scarring.
Initial*
I understand that it is necessary to maintain the use of my prescribed Skin Deep Skin Tone Enhancement System protocol throughout the treatment period and also during the maintenance period. This is necessary to retain the benefits during the program.
Initial*
I understand that products with hydroquinone should not be used when pregnant or lactating.
Initial*
I understand a sunscreen of at least SPF 50 is to be used on a daily basis and to practice sun safe guidelines when outdoors.
Initial*
I understand that I must adhere to the guidelines prescribed.
Initial*
Consent*
I have read and fully understand the above, received satisfactory answers to my questions and had a chance to discuss alternative treatments.
Patient's Name*
First Last
Email Address*
Phone*
Date*
Date Format: MM slash DD slash YYYY
Signature*

Skin Tone Enhancement System Consent (with Hydroquinone 4%)

Skin Tone Enhancement System Consent (with Hydroquinone 4%)

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