VI Peel Client Consult Form

VI Peel Form

"*" indicates required fields

MM slash DD slash YYYY
The VI Peel® contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel® will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.
  • 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 (i.e. Lupus) or liver disease/disorder as well as any condition that may weaken their immune system
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY