CONSENT FOR CHEMICAL SKIN PEELS (Medium to Deep)

Patient______

Date______Time______

I hereby authorize Dr. Peter Schmid, and his associates to perform the procedure known as a medium/deepchemical 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).

Pleaseinitial______

  1. Nature and Purpose of Chemical Skin Peels

Chemical peeling is a cosmeticprocedure 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______

  1. 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.

Please initial______

  1. Anesthesia

I understand that local, intravenous sedation, or general anesthesia is normally required when certain medium to deep chemicals peelare 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______

  1. Alternatives to Chemical Peels

Alternatives for improving thetexture and complexion of the face includenon-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______

  1. 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______

  1. 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______

  1. Allergies

I have provided Dr. Schmid with a complete list of my known allergies. My allergies (i.e. to medications, latex or anesthetics) include: ______

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  1. 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______

  1. 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