Chemical Peel Consultation/Consent Form | Aesthetics Forms Portal

Chemical Peel Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical Information

Have you used Accutane within the past six months? *

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.

Are you currently taking any medications (oral or topical)? *

Please list: *

Do you have any allergies? *

Please list: *

This is an informed consent document which has been prepared to assist your Skincare Specialist to inform you about skin peel and skin treatment procedure(s), the risks, and alternative treatment options.
It is very important that you read this information carefully and completely.

Contraindications

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for skin peel treatment and must be disclosed and discussed with the specialist prior to treatment.

Please check all that apply and give details below:

If you have ticked any of the above contraindications please give details:

Chemical Peel Information

An acid solution is used to peel away the skin’s damaged outer layers. The new cells and collagen are stimulated during the healing process to produce a smoother, tighter, younger-looking skin surface. A peel does not eliminate sagging or excess skin. Each treatment is customized for patient skin type, specific problem areas and the delicate areas of the face. The depth of the peel is dependent on the concentration and type of acid, the duration of contact, and a person’s skin type and sensitivity.

Please read the following information carefully and tick the appropriate boxes to show your understanding and acceptance: *

The Chemical Peel procedure has been thoroughly explained. I realize that no promises or guarantees have been made. I understand that the treatment may be repeated several times to achieve complete satisfaction. I understand that this treatment is voluntary on my part. My signature below indicates that I have agreed to receive the Chemical Peel treatment(s).

Signature: *

Tap or click on the signature above to sign

PRE TREATMENT INSTRUCTIONS

- Do not apply Retin-A, Renova, Tazorac, and/or Differin 2 weeks prior to, and for 2 weeks after your peel, to the treatment area.
- Do not sun tan or use the tanning bed 4 weeks prior to, and for 4 weeks after your treatment.
- Stop any type of depilatory treatments (waxing, depilatory creams) to the area of treatment, 2 weeks prior to, and for 2 weeks after your peel.
- Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of treatment, 4 weeks before and for 4 weeks after your peel.

POST TREATMENT INSTRUCTIONS

- When cleansing, do not scrub. Use a gentle cleanser as directed by your Skincare Specialist at (Company Name).
- With any peel, your skin may start to peel 1-3 days after the peel and continue to peel for up to 5 more days; however, it is also possible your skin may not peel at all.
- Do not peel, pick or scratch the treated area, as this may result in scarring.
- Apply polysporin, bacitracin or Vaseline to dry flaky areas or as directed by your Skincare Specialist at (Company Name).
- 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.
- If given a cortisone cream by your Skincare Specialist, please apply it 1-3 times per day to red irritated areas or as directed. Follow any additional and all instructions given to you by your Skincare Specialist.
- Always wear your sunscreen; apply a sunscreen with SPF 30 every morning.

Consent

Please read the following information carefully and tick the appropriate boxes to show your understanding and acceptance:

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE ABOVE INFORMATION AND THEREBY CONSENT AND AGREE TO THE TREATMENT WITH ITS ASSOCIATED RISK. I HEREBY CONSENT TO RECEIVE A CHEMICAL PEEL.

Signature: *

Tap or click on the signature above to sign