I request that KAILANA CLINIC, Kailly Woods and or his/her associates perform an AHA 40 skin peel on my face. 

I understand that AHA 40 is a programme of treatments and that several treatments may be required to achieve the best possible results for me. The degree of improvement is dependant upon many variables and cannot be guaranteed. 

I agree to follow the post peel instructions that will be supplied to me in order to minimise any potential discomfort and maximise the degree of improvement achieved. I understand that there are potential risks and complications associated with any medical procedure, including a glycolic skin peel. I acknowledge that no guarantee has been made to me about the results from this peel. 

I have been informed that some of the possible risks and complications of this peel may include, but are not limited to, swelling, redness, scabbing or peeling of the treated skin or surrounding areas; cold sores; prolonged skin sensitivity to wind and sun and/or areas of persistent increased or decreased pigmentation. 

I understand that although complications from a glycolic peel are very rare, prompt treatment is necessary if they occur. In the event of any complications, I will immediately contact the therapist who performed the glycolic peel. 

I understand that I cannot have a different accelerated exfoliation, microdermabrasion and or/different skin peel within 7 days of the AHA 40 skin peel. 

I certify that: 

I have accurately described my previous medical history, including any conditions and/or complications that might preclude receiving epiderma5 AHA 40. 

I am 18 years or older 

I am not pregnant or breast feeding 

I understand and will follow all post peel instructions 

I have had the opportunity to ask questions and all these questions 

have been answered to my satisfaction

TREATMENT ADVICE FOR CLIENTS 

Contraindications to AHA 40 40% Glycolic Skin Peel 

• Pregnancy and breast feeding
• Roaccutane
• Dermabrasion
• Lasertreatment
• Broken skin
• Sunburn
• Eczema/psoriasis 
• Chemotherapy and radiation 
• Active herpes 

PRE AND POST PEEL ADVICE 

• Do not use glycolic acid products 12-24 hours before treatment 
• Please do not use any retinol products for 4 weeks
• If any redness persists do not go back to using glycolic acid until it is resolved 
• Skin may feel drier or tighter – this is quite normal. Apply epiderma5 Daily Balm
• Do not use a sunbed, sunbathe, sauna or steam bath for 7 days after a peel 
• Always use recommended sun protection epiderma5 Daily Defence
• Avoid electrolysis, waxing, bleaching (face) for 7 days 
• Do not swim in chlorinated water for 3-5 days
• No excessive exercise immediately after treatment 
• Make up can be applied, mineral is recommended 
• Take directed advice if undergoing epilation, laser or IPL treatment