Chemical Peel Consultation and Consent Form

Client Details


Medical Information

A skin peel will NOT be suitable for you at this time. Please wait for at least six months after you finish your Accutane before you arrange a skin peel.


Emergency Contact Details


Pre-Treatment

A chemical peel requires a skin preparation programme prior to treatment. Your practitioner will discuss this with you. 

In addition to the skin preparation programme, the following is advised:

  • Don't exfoliate. 
    • Since a chemical peel is an in-depth form of exfoliation, it’s important that you don’t exfoliate for at least a week or more before your appointment. Even though you might not actively exfoliate with a scrub or exfoliant, watch out for ingredients in your every-day skin products that may have an exfoliating effect. If you use these products before your appointment, you could unknowingly cause some damage to your skin.
  • Stop using certain medications. 
    • Products like anti-aging or anti-acne medications could impact how your skin tolerates the peel. Do NOT discontinue any medication before seeking medical advice. Please delay your chemical peel treatment until you have discussed with your doctor.
  • Stay hydrated. 
    • Your skin should be well-hydrated on the day of your chemical peel. Stop using any products that could be drying out your skin at least a few days before your appointment. And keep drinking water!
  • Consider the timing. 
    • There is a certain amount of recovery time that will be needed immediately following a chemical peel. If you’ve got a big event happening sometime in the next couple of weeks, wait until after to get a peel.

Treatment Information

A chemical peel is a skin-resurfacing procedure in which a chemical solution is applied to the skin to remove the top layers. The skin that grows back after a peel is smoother and younger looking. Chemical peels are used to treat acne, wrinkles, pigmentation and scarring — typically on the face but also on the chest and back. Peels can be done at different depths — light, medium or deep — depending on desired results. Each type of peel uses a different chemical solution and can be used to treat various skin problems.

 

Depending on the issues you’re addressing, you’ll choose a peel in one of three depths:

  • Light chemical peel
    • A light (superficial) chemical peel removes the outer layer of skin (epidermis). It can be used to treat fine wrinkles, acne, uneven skin tone and dryness. We offer light chemical peels for the treatment of acne and anti-aging.
  • Medium chemical peel
    • This type of chemical peel removes skin cells from the epidermis and from portions of the upper part of your middle layer of skin (dermis). A medium chemical peel can treat wrinkles, acne scars and uneven skin tone.
  • Deep chemical peel
    • A deep chemical peel removes skin cells from the epidermis and from portions of the mid to lower layer of your dermis. Your practitioner might recommend a deep chemical peel if you have deeper wrinkles, scars or precancerous growths.

 

You’ll be lying face-up during the procedure, which should last no more than an hour to complete. The practitioner will then gently apply the chemical to your face or other areas that you want.

 

When the chemical of choice is applied to your skin, you can expect to experience the following sensations:

  • Tingling
    • The chemical applied will probably cause you to feel a little bit of tingling and itching, which are totally normal. Anything that feels painful should be communicated to the practitioner.
  • Heat or Cold
    • After the peel is applied, you might notice the temperature of your skin starts to change slightly, in either direction. Some people say their skin feels a little warmer, while other say their skin feels a little cooler. Either one of these is normal and just depends on the individual.
  • Taut Skin
    • Chemical peels help to extract any impurities in the skin. While that happens, you might feel a sensation of tightness, which is also normal as long as it’s not excessive.

 

Fitzpatrick skin types:

  1. Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
  2. White skin, often with blue eyes - burns and does not tan easily
  3. Fair skin with brown eyes and brown hair - burns first then tans
  4. Light brown skin, dark eyes, and dark hair - burns a little and tans easily
  5. Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
  6. Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Possible Risks and Side Effects

You may experience a slight tingling sensation as the peel works during your treatment, but this is completely normal.

 

Possible side effects include:

  • Redness, scabbing and swelling.
    • Normal healing from a chemical peel involves redness of the treated skin. After a medium or deep chemical peel, redness might last for a few months.
  • Scarring.
    • Rarely, a chemical peel can cause scarring - typically on the lower part of the face. Antibiotics and steroid medications can be used to soften the appearance of these scars.
  • Changes in skin color.
    • A chemical peel can cause treated skin to become darker than normal (hyperpigmentation) or lighter than normal (hypopigmentation).
    • Hyperpigmentation is more common after superficial peels, while hypopigmentation is more common after a deep peel.
    • These problems are more common in people with brown or black skin and can sometimes be permanent.
  • Infection.
    • A chemical peel can lead to a bacterial, fungal or viral infection, such as a flare-up of the herpes virus - the virus that causes cold sores.
  • Heart, kidney or liver damage.
    • A deep chemical peel uses carbolic acid (phenol), which can damage heart muscle and cause the heart to beat irregularly. Phenol can also harm the kidneys and liver. To limit exposure to phenol, a deep chemical peel is done a portion at a time, in 10- to 20-minute intervals.

 

A chemical peel isn't for everyone. Your practitioner might caution against a chemical peel or certain types of chemical peels if you:

  • Have taken the oral acne medication 'Isotretinoin' in the past 6 months
  • Have a personal or family history of ridged areas caused by an overgrowth of scar tissue (keloids)
  • Are pregnant
  • Have frequent or severe outbreaks of cold sores

Aftercare Advice

Please read carefully.

 

Peeling:

Perhaps the most noticeable symptom that you’ll experience is peeling on your face. That’s the whole point of a chemical peel: to “peel” old skin to reveal healthier skin beneath.

You can expect your skin to peel after about the third day, not right away. It will continue to peel over the first week following the procedure. Deeper peels with phenol can take as much as 10 days to finish peeling.

It is also possible your skin may not peel at all.

 

Sensitivity:

Your skin shouldn’t feel too weird after the procedure, but you’ll still be a little sensitive for a few days. You’ll also notice that your skin will be a bit more sensitive to some of your skin care products when you apply them.

As such, avoid exfoliating products for a few days. Use a gentle cleanser and a hydrating gel to soothe your skin, and steer clear of any hot water on your face. Try to stay out of the sun until your skin has healed, and always wear your sunscreen; apply a sunscreen with minimum SPF 30 every morning.

 

Aftercare:

  • Stay out of the sun until your skin has healed - Always wear your sunscreen
  • Avoid using makeup or other cosmetics until your practitioner gives you the go-ahead
  • You can use ice packs for 20 minutes at a time, or a cool fan, to help relieve discomfort at home
  • When cleansing, do not scrub - Use a gentle cleanser as directed by your practitioner
  • Do not peel, pick or scratch the treated area, as this may result in scarring
  • Apply polysporin, bacitracin or Vaseline to dry flaky areas
  • Do not have any other facial treatments for at least 2 weeks after your peel or until the skin is smooth and back to normal

 

Recovery Time:

  • Light chemical peels
    • Recovery time is about four to seven days.
    • Your skin may temporarily be lighter or darker.
  • Medium chemical peels
    • Your skin will recover about five to seven days after a medium chemical peel, though you may have redness that persists for months.
    • Your skin will initially swell, and then form crusts and brown blotches before revealing new skin.
  • Deep chemical peels
    • Deep chemical peels may cause severe swelling and redness, with burning or throbbing sensations.
    • It’s common for the eyelids to swell shut.
    • It will take about two weeks for the new skin to develop, though white spots or cysts may last several weeks.
    • It’s common for redness to last for several months.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me. 

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the practitioner and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Chemical Peel treatment(s) to be carried out.



Tap or click on the signature above to sign


SUBMIT

(disabled)