Beautox Bar LLC, 7372 Kirkwood Court, Maple Grove, MN 55369
VI Peel™ Consent Form
The VI Peel™ contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peels™
will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation
(including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars;
and stimulate the production of collagen, for firmer, more youthful skin.
• Patients who are pregnant or who are breast feeding
• Patients who have an aspirin allergy or phenol allergy
• Patients who have used Accutane within the past 3 months
• Patients who on any medications that causes photosensitivity
• Patients who have active cold sores, warts, open wounds or history of herpes simplex
• Patients who are undergoing chemotherapy and or radiation therapy
• Patients with a history of an autoimmune disease or any condition that may weaken their immune
Please read and initial the following:
_______Prior to receiving treatment I have communicated with the Registered Nurse about any
conditions or medications that may contraindicate this procedure
_______ I understand that there may be some degree of discomfort such as burning, stinging, redness,
heat or tightness during and a week after the procedure.
______ I understand that there is no guarantee of the final results of the peel. Occasionally
hyperpigmentation may develop which may persist for week or months after the peel.
_______ I understand although complications are very rare, sometimes they may occur. In the event of
any complications, I will immediately contact the Registered Nurse who performed the treatment.
_______I understand that maintenance VI Peel™ treatments are necessary to maintain results as well as
the recommended VI DERM™ skin care regimen.
______I understand the extended direct sun exposure including tanning beds are strictly prohibited before
and after receiving the VI Peel™.
______I understand that I must protect my skin with sunscreen and avoid sun exposure during the
______I understand that this is an elective cosmetic procedure and is non-refundable. I understand
payment is my sole responsibility.
_____ I understand that no other chemical peels or medical device treatments may be performed on my
skin until the Registered Nurse releases me to do so.