Beautox  Bar  LLC,  7372  Kirkwood  Court,  Maple  Grove,  MN  55369                          

www.beautoxbar.com  

 

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.  
Contraindications:  

• 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 
system  

 

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 
exfoliation process. 
 ______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.  

 

___________________________________ _______________________________  
Patient signature  

 

 

 

 

 

Date 

___________________________________ _______________________________ 
RN signature   

 

 

 

 

 

Date