I have given an accurate account of any over-the-counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have
not disclosed to my skin therapist. I am not ingesting or using topically any other over-the-counter product
or prescription medication/agent that has not been disclosed to my skin therapist. I am not presently
pregnant or lactating and I am over the age of eighteen (18). I have not had any recent radioactive or
chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory
(such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any auto
immune disease, active herpes blisters, or any other existing condition that may interfere with the positive
outcome of this treatment.