Informed Consent

Glycolic acid peeling is a medical procedure that requires the informed consent of the patient. The medical doctor must obtain from the patient a well-standardized formal consent that shows that all information about the medical procedure performed was explained to the patient. We include below the formal consent form submitted to the patient before the glycol-ic acid peeling procedure.

I,_, after carefully reading the information regarding the glycolic acid peeling prodedure, give my informed consent to undergo glycolic acid peeling treatment.

I have been well informed about side effects that the procedure could cause.

I have been well informed of temporary effects of the therapy.

I confirm that I have informed the medical doctor about all actual pathologies or pathologies that I have had.

I confirm that I have informed the medical doctor about pharmacological therapies that I am currently receiving or have received in the past.

I confirm that I want to perform the treatment of my own free will without any physical or moral conditioning and I confirm that I have the right to interrupt the therapy such as I want without the necessity of justifying my decision.

Surname and name

Date of birth

Place of birth

Address

Town

Signature of the patient Date

I, medical doctor,_, confirm that I have explained with accuracy the type, aim and possible risks of the medical procedure to be performed on the patient indicated, who has given consent to begin the treatment.

Surname and name of the medical doctor

Signature of the medical doctor

Date

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