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CONSENT TO MELANAGE PEEL/MINIPEEL TREATMENT
The instructions provided in this informed consent should be followed by all patients receiving a Melanage Peel or MiniPeel Treatment. You will be asked to sign this form acknowledging that you have read and understood all of the information presented. MELANAGE PEEL/MINIPEEL TREATMENT PURPOSE: The Melanage Peel/MiniPeel Treatment
is a superficial peel designed to improve the texture and appearance of your skin.
PATIENTS WHO SHOULD NOT BE TREATED: The Melanage Peel/MiniPeel Treatment SHOULD
NOT be used on patients with active cold sores or warts, skin with open wounds, sunburn, excessively
sensitive skin, dermatitis or inflammatory rosacea in the area to be treated or an autoimmune disease.
Inform your medical professional if you have any history of herpes simplex. You should also not have a
Melanage Peel/MiniPeel Treatment if you have a history of allergies, rashes or other skin reactions,
cancer or may be sensitive to any of the components of this treatment. This peel is not recommended if
you have taken Accutane within the past year, or received chemotherapy or radiation therapy. Melanage
Peel/MiniPeel Treatment should not be administered to pregnant or breastfeeding (lactating) women.
ONE WEEK BEFORE YOUR MELANAGE PEEL/MINI PEEL TREATMENT: Avoid these
products and/or procedures:
• Patients who have medical cosmetic facial treatments or procedures (e.g. laser therapy, surgical procedures, cosmetic filler, microdermabrasion, etc) should wait until skin sensitivity completely resolves before having a Melanage Peel/MiniPeel Treatment. • Patients who have had BOTOX injections should wait until all bruising subsides and the full effect of their treatment is seen before receiving the Melanage Peel/MiniPeel Treatment. TWO TO THREE DAYS BEFORE YOUR MELANAGE PEEL/MINIPEEL Avoid these products
and/or procedures:
• Retin-A® (tretinoin), Renova® (tretinoin), Differin® (adapalene), Tazorac® • Any products containing Retinol, AHA or BHA, or Benzoyl Peroxide. • Any exfoliating products that may be drying or irritating Note: the use of these products/treatments prior to your peel may increase skin sensitivity and cause
stronger reactions.
AFTER YOUR MELANAGE PEEL/MINIPEEL TREATMENT : It is crucial to the health of your
skin and success of your peel that these guidelines be followed:
Your skin may have a light yellow tinge immediately after removal of the Melanage 1 Masque or MiniPeel solution. This is temporary and will fade in a few hours. It is imperative that you use a sunscreen with an SPF of at least 30 and avoid direct sunlight for at least 1 week. Best results will be obtained with regular daily use of such sunscreen. Patients with hypersensitivity to the sun should take extra precautions to guard against exposure immediately following the procedure as their skin may be more sensitive. Your skin may be more red than usual after removal of the Melanage 1 Masque or MiniPeel solution. Please avoid strenuous exercise during this time. Approximately 48 hours after the treatment, your skin will start to peel. This peeling will generally last 2 to 5 days. DO NOT PICK OR PULL THE SKIN. When washing your face, do not scrub, do not use a wash cloth. Use the Anti-Redness Foaming Cleanser provided. Apply the Anti-Redness Soothing Balm as directed and as needed to relieve dryness, tightness and itching. Wait until the peeling is complete before having ANY OTHER FACIAL PROCEDURES, INCLUDING: • Facials • Microdermabrasion • Laser treatments • Laser hair removal • BOTOX injections • Injectable fillers ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR PEEL: It is common and
expected that your skin will be red and possibly itchy and/or irritated. It is also possible that other
adverse experiences (side effects) may occur. Although rare, the following adverse experiences have
been reported by patients after having a Melanage Peel/MiniPeel Treatment: skin breakout or acne, rash,
dark spots (hyperpigmentation), swelling and burning.
Call the office immediately if you have any unexpected problems after the procedure.

LACK OF EFFECT: Although most people experience peeling of their facial skin, not every patient
notices that their skin peels after a Melanage Peel/MiniPeel Treatment. Lack of peeling is NOT an
indication that the peel was unsuccessful. If you do not notice actual peeling, please know that you are
still receiving all the benefits of the Melanage Peel/MiniPeel Treatment, such as: stimulation of collagen
production, improvement of skin tone and texture, and diminishment of fine lines and pigmentation.
There are a number of reasons why a patient may not have peeling or may experience minimum peeling. The reasons may include: • Having peels regularly with a short interval between peels • Frequent use of Retin-A, AHA, or other peeling agents prior to the Melanage Proper skin evaluation by your skin care professional prior to your peel is important and will help predict the outcome of your peel. Please read and initial the following: I understand that the Melanage Peel/MiniPeel Treatment is not an exact science and the degree of improvement is variable. ______ I understand that occasionally there is no visible improvement and another form of treatment may be required.______ I do not have any conditions described in the “Patients Who Should Not Be Treated” section.______ By my signature below, I acknowledge that I have read this Melanage Peel/MiniPeel Treatment informed consent form and understand it. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the Melanage Peel/MiniPeel Treatment. ___________________________________________________________________________ For Office Staff: Please make a copy of the completed and signed consent form. Place the original in the patient’s file and give one copy to the patient to take home.

Source: http://beauty-by-design.net/images/Melanage-MiniPeel_consent_form.pdf

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