Nu-Derm Program Consent

Nu-Derm Program Consent
The creams must be used in the prescribed fashion according to the written instructions and descriptions given to me. I understand that I will experience varying degrees of the following symptoms: Dryness - Redness - Exfoliation/Peeling - Itching - Sensitive Skin - Burning - Wrinkles May Look Worse - Acne May Look Worse
Initial*
These symptoms will lessen and eventually subside as my skin builds tolerance. I agree to continue with the use of the Nu-Derm products and to return for follow-ups as directed. Doing so will help with my safety and provide adjustments towards maximizing results.
Initial*
I understand the best results are achieved with adherence to the program over several weeks and/or months.
Initial*
I understand that excessive application of the products or picking, rubbing the skin can cause a great deal of discomfort and even blistering, especially in the early weeks of treatment. If any reactions are initiated to the point of skin breakdown or infection, I will contact the office immediately. Careless inattention to such reactions may result in complications such as infection, injury, discoloration, or possible superficial scarring.
Initial*
I understand that it is necessary to maintain the use of my prescribed Nu-Derm protocol throughout the treatment period and also during the maintenance period. This is necessary to retain the benefits during the program.
Initial*
I understand that no guarantee or assurance has been given to me as to the results that may be obtained.
Initial*
I understand that a sunscreen of at least SPF 50 is to be used on a daily basis and to practice sun safe guidelines when outdoors.
Initial*
I understand that I must adhere to the guidelines prescribed.
Initial*
Consent*
I have read and fully understand the above, received satisfactory answers to my questions and had a chance to discuss alternative treatments.
Patient's Name*
First Last
Email Address*
Phone*
Date*
Date Format: MM slash DD slash YYYY
Signature*

Nu-Derm Program Consent

Nu-Derm Program Consent

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