Patient Name: <PersonalInfo.FullName>	
	DOB: <PersonalInfo.DOB>	
		
	Date: <System.Date>	
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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 acneic 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, hydroquinone or phenol allergy
•	Patients who have used oral isotretinoin (Accutane) within the past 6 months
•	Patients who have active cold sores, warts, open wounds or history of herpes simplex
•	Patients who are undergoing chemotherapy and or radiation therapy within 6 months
•	Patients with a history of an autoimmune or liver disease/disorder as well as any condition that may weaken their immune system

{INITIALS_50_PERC}	Prior to receiving treatment, I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.	
{INITIALS_50_PERC}	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.	
{INITIALS_50_PERC}	I understand that there is no guarantee of the final results of the peel. Occasionally, hyperpigmentation may develop which may persist for a week or months after the peel.	
{INITIALS_50_PERC}	I understand that, although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.	
{INITIALS_50_PERC}	I understand if I have any acneic condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.	
{INITIALS_50_PERC}	I understand that maintenance of VI Peel™ treatments are necessary to maintain results as well as the recommended VI DERM™ skin care regimen and SPF 50+.	
{INITIALS_50_PERC}	I understand that extended direct sun exposure, including tanning beds. is strictly prohibited before and after receiving the VI Peel	
{INITIALS_50_PERC}	I understand no activities involving excessive sweating can be done for 72 – 96 hours after the treatment (exercise, sauna, hot tub, steam room)	
{INITIALS_50_PERC}	I understand that I must protect my skin with VI DERM SPF 50+ and avoid sun exposure during the 7-day exfoliation process.	
{INITIALS_50_PERC}	I understand that this is an elective cosmetic procedure.	
{INITIALS_50_PERC}	I understand that no other chemical peels, facial machine brushes or medical device (laser, IPL, etc.) treatments may be performed on my skin until my Physician/Clinician releases me to do so.	

Patient Signature	{SIGNATURE_50_PERC}	
Date	<System.Date>	

Practitioner Signature		
Date	<System.Date>