CONSENT FOR CHEMICAL SKIN PEELS (Medium to Deep)
Patient_________________________________________
C.
Date_______________________ Time_______________
I hereby authorize Dr. Peter Schmid, and his associates to
perform the procedure known as a medium/deep chemical
peel on ________________________________.
(Name of Patient)
I have completely read and understand the written and
verbal information provided to me regarding chemical
peels. I have read and understand all of the preoperative
and postoperative instructions and the preoperative
medication avoidance list.
I have reviewed these
documents thoroughly with Dr. Schmid. I fully understand
this procedure has limited applications. Furthermore, I am
aware that the practice of medicine and surgery is not an
exact science and, although good results are anticipated, I
acknowledge and understand that no guarantees or
assurances have been made to me as to the results or
outcome of my procedure(s).
Please initial________
A. Nature and Purpose of Chemical Skin Peels
Chemical peeling is a cosmetic procedure by which
the skin is exfoliated with selective acids/chemicals
to improve the appearance of the skin with respect to
sun damage, precancerous changes, skin texture and
wrinkling. The goal is to achieve improvement of the
skin.
Please initial_______
B. Risks
Dr. Schmid has discussed in detail the risks as
follows and other risks involved with this procedure.
I understand that among the known risks are
anesthesia risks, medication reactions, bacterial, viral
or fungal infection, bruising, chronic or recurrent
swelling, prolonged redness of the skin, prolonged
skin tenderness or pain, itching and hypersensitivity,
increased appearance of broken capillaries and
flushing, poor wound healing, unfavorable scarring,
poor skin healing or skin loss (necrosis), cosmetic
deformity,
blotchy
irregular
pigmentation,
hyperpigmentation, hypopigmentation, lower eyelid
rounding, eye injury, tooth injury/staining, acne,
milia, dermatitis or other skin reactions, poor clinical
response or persistent wrinkles, and mental
depression. I understand that permanent lightening of
the treated skin is expected in the majority of patients
undertaking medium to deep chemical peels, and a
line of demarcation could be detectable between
treated and untreated skin. I understand that with the
natural aging process certain wrinkles will return and
new wrinkles will appear with time. I am aware that
in addition to the risks specifically described above,
there are other risks that may accompany any surgical
procedure. I understand that if subsequent treatments
are required or requested, this will be additional
expense to me for equipment, anesthesia costs, and
surgeon’s fees.
Please initial_______
I recognize that, during the course of the procedure,
unforeseen conditions may necessitate additional or
different procedures than those set forth above. I
therefore, further authorize and request that the
above-named surgeon, his assistants, or his designees
perform such procedures as are, in his or their
professional judgment, necessary or desirable.
D.
E.
F.
G.
Please initial_______
Anesthesia
I understand that local, intravenous sedation, or
general anesthesia is normally required when certain
medium to deep chemicals peel are performed. I
consent to the administration of the proposed
anesthetics by Dr. Schmid or his designee.
I am aware that risks are involved with the
administration of any type of anesthesia and sedation,
such as allergic reactions, toxic reactions, cardiac or
respiratory arrest. I understand that severe anesthesia
reactions may result in a hospital admission at an
additional expense to me.
Please initial_______
Alternatives to Chemical Peels
Alternatives for improving the texture and
complexion of the face include non-invasive
laser/light treatments, CO2 laser skin resurfacing or
dermabrasion. These techniques are limited in their
improvement of skin laxity and are not a replacement
for surgical lifting procedures (i.e., face lifts,
blepharoplasties, et al.)
Please initial_______
Photographs and Computer Imaging
I consent to be photographed before, during and after
the treatment, and these photographs shall be the
property of Dr. Schmid and may be published in
scientific journals and/or shown for scientific
reasons. I understand that, if computer imaging was
performed on my photograph, this has been used for
communication purposes only. Computer imaging is
not a guarantee of results.
Please initial_______
Smokers
I have been extensively counseled about the adverse
effects of smoking with respect to medical, surgical
and postoperative outcomes. I understand that
smoking adversely affects my overall health, multiple
organ systems, and compromises postoperative
healing and results. Smoking may also adversely
affect anesthesia and medical outcomes during
surgery. Smoking has a direct adverse effect on blood
vessels, the blood supply to the skin, healing factors
and may lead to blood clotting problems, excessive
bleeding, blood fluid collections, and compromised
blood flow which may result in skin loss (necrosis)
and scarring and the final outcome of the
postoperative result. These results are usually less
optimal than in the nonsmoker. I have discontinued
smoking preoperatively, as instructed by Dr. Schmid,
in preparation for surgery and the postoperative
course.
I understand and agree that smoking
postoperatively may directly affect the immediate
and long-term outcome of my results and agree to
abide by Dr. Schmid’s recommendations for
smoking.
Please initial_______
Allergies
I have provided Dr. Schmid with a complete list of
my known allergies. My allergies (i.e. to medications,
latex or anesthetics) include: ___________________
__________________________________________
___________________________________________
___________________________________________
__________________________________________
__________________________________________
__________________________________________.
H.
I.
Cooperation and Follow Up Care
I agree to keep Dr. Schmid and his staff informed of
any change in my permanent address. I agree to
cooperate with them before, during and after my
treatment.
Please initial_______
I have been informed of and understand fully my
instructions for postoperative skin care and healing. I
understand that the success of the procedure is to a
great extent dependent on my adhering to all of the
instructions, postoperative care, activity restrictions,
medication restrictions and precautions. I understand
that failing to adhere to my instructions can
jeopardize the healing and results of my procedure. I
understand that there is a period of time for recovery
associated with my procedure. This period of time
may vary from patient to patient.
Please initial_______
Informed Consent
I have had sufficient opportunity to discuss my
condition and proposed treatment with Dr. Schmid
and his staff, and all my questions have been
answered to my satisfaction. I believe I have
adequate knowledge on which to base an informed
consent to the proposed treatment.
I have read the above consent and fully understand
the same and acknowledge my review of the
information by initialing each paragraph. I do
authorize Dr. Schmid to perform this procedure on
me.
PATIENT OR LEGAL
GUARDIAN________________________________
Witness____________________________________
Witness____________________________________
PMS/CHEM/3-2002