Zo Peel Consent Form
Skinlogic Med Spa recommends using an at-home regimen of skin health productsto maximize the benefits. This screening will determine who is a good candidate for the ZO 3 step Peel Protocol. YES answers to any of the following questions may disqualify you
NOYES Are you pregnant or lactating?
NOYES Have you used Accutane® or any prescription retinoid products
NOYES (Retin-A®. Renova®) in the last 3 months?
NOYES Have you used products containing retinol in the past week?
NOYES Are you allergic or sensitive to aspirin?
NOYES Are you undergoing any type of radiation or chemotherapy?
NOYES Do you have herpes or cold sores?
NOYES Within the last week. have you had any facial waxing, electrolysis or used any depilatories?
NOYES Do you have any form of auto-immune disease (diabetes. lupus. etc.)?
Do you have a sensitivity or allergy to:
NOYES Have you had facial cosmetic surgery in the last month (laser resurfacing, dermabrasion. chemical peel. face lift. blepharoplasty, Botox®. in jectible fillers)?
NOYES In the past 4 weeks have you been exposed to the sun?
NOYES If so, do you have a suntan?
* Note: Some redness is anticipated after the peel.
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Document Name: Zo Peel Consent Form
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