Form

Chemical Peel

Client Consultation Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Emergency Name

First NameLast Name
Emergency Contact

Area CodePhone Number
How did you hear about me?*

InstagramFacebookGoogleWebsite/Online SearchOther
If referral, please list name.
Tell me about your skin.

Please answer each question to the best of your ability.
What are your skincare interests?*

Skincare Consultation/AdviceHome Care ProductsClinical TreatmentsAge ManagementAcne Treatment/ManagementRosacea
What are your skin care challenges?*

Wrinkles/Fine LinesHyperpigmentation/Sun DamageAcne/Acne ScarringAgingMelasmaSensitivity
Please feel free to get into detail.
Have you ever had a facial or chemical peel before?*

YesNo
What skin care products do you currently use?*

Cleanser/Face washFace Scrub/ExfoliantsTonerSerumMoisturizerSunscreenEye ProductsOther
Please list current products being used.
Skin Self-Analysis

If unsure, please head back to my website to take the Skin Type Quiz
Are you wearing a daily sunscreen?*

YesNo
Is your skin:*

Oily/Acne ProneDryNormalSensitiveCombination (Oily and Dry)
Have you ever been treated for a skin condition? If yes, what condition?
How did you treat the condition?

DermatologistAestheticianSelf Treated with products purchased from drug store or department store
Are you currently being treated for any skin condition?
Medical History
Are you currently using any medications for skin treatments:

AccutaneCortisoneStaticinBenzoyl PeroxideRetin ASufferDesquamXZeracFosdexGlycolic AcidSalicylic AcidLactic AcidRenovaClindamycinTazorateneMetrogel
If so, when was the last time you used these medications?*

Yes, currently usingYes, but not within the last 7 daysNoNot Sure
Please keep in mind, if you have use ANY form of Retinol in the last 7 days, you will not be able to get any facial service/chemical peel.
Have you used or been prescribed any medications (topical or oral) for acne/acne control?*

YesNo
If yes, please specify what and date last used.
Have you received any of these hair removal services in the last 7 days?*

WaxingSugaringThreadingElectrolysis/LaserDermaplaningNone
Please keep in mind, if you have received any of these services in the last 7 days, you will not be able to get any facial/chemical peel.
Have you experienced any of these health conditions in the past or present?*

AIDS/HIVArthritisAsthmaAuto-Immune DisordersCancer/Systemic DiseaseContact LensesDepression/AnxietyDiabetesEpilepsy/Seizure DisordersFrequent Cold SoresHeadachesHeart ConditionHepatitisHerpesHigh Blood PressureHormone ImbalancePacemakersOtherNone
If you checked yes to any of these please provide further information.
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances/Essential OilsOtherNone
If other, please specify.
Are you a smoker?*

YesNo
Do you drink more than 4 caffienated beverages a day? (Tea, Coffee, Soda, Energy Drinks)*

YesNo
Female Clients
Are you pregnant?*

YesNoN/A
Are you currently breastfeeding?*

YesNoN/A
Any menopause issues?*

YesNoN/A
Male Clients
What is your current shaving system?

Razor/Wet ShaveElectric
Do you experience irritation from shaving?

YesNo
GlyMed Plus® advises the treatment you will receive is ONLY available through a licensed and trained skin care professional.GlyMed Plus® Purely Professional clinical treatments are immediately effective and produce long-term results when all directions, as advised by GlyMed Plus® and your licensed skin care professional, are adhered to. These special noninvasive skin performance treatments remove the outer layers of micro damaged skin—signaling new cells to emerge, increasing collagen, elastin and hydration levels thereby producing clearer and more younger looking and acting skin. Additional benefits may include the drying of active acne, dislodging or purging of blackheads, reduction of superficial wrinkles or scarring, improving the appearance of mature or aging skin, correcting sun damage, lightening pigmentation disorders such as sun or age spots, and controlling the effects of other health and aging skin challenges. COMPLIANCE in your skin care program will determine the level of success and outcome of your treatment. Effective, long term results are dependent upon you. Consistency with your
recommended continuance of GlyMed Plus® home skin care products exclusively as prescribed by your licensed skin care professional cannot be emphasized enough.
It is strongly advised you continue your professional in-clinic appointments as scheduled. Report any changes in health, diet, lifestyle or any reactions to your esthetician or physician. Apply sunscreen as directed by your esthetician or physician, avoid excess sun exposure and avoid tanning beds. Inform your esthetician or physician of any recreational plans for the week following your treatment.

No guarantee is made or implied regarding results, peeling times or level of discomfort. Your treatment may involve the application of several peels at one, two or four week intervals, as determined by your esthetic/professional technician. It may include the use of GlyMed Plus® skin brightening agents and sun-protection products. GlyMed Plus® advises a patch test (usually requiring a nominal fee) applied behind the ear to gauge possible reactions. Depending on your treatment, you may experience some temporary discomfort, including stinging or warm flushing, similar to a mild burning sensation. This is NORMAL and generally fades within five minutes. During the few minutes following the initial treatment, you will experience tightening of the skin to varying degrees. The skin can appear red and become progressively rosier, occasionally turning a tan to brown color, depending upon formula and application variances. For most individuals, peeling starts at day five but can be as early as 48 hours. It is impossible to pre-determine how much peeling will occur. Deeper penetration and more active solutions may result in sensitivity for several hours after the procedure, with some significant peeling for up to ten days. Your skin can feel tight, dry and you may experience redness for up to ten days.

To enhance your treatments and relieve discomfort for the period following your treatment, you are advised to do the following:
• Drink a full glass of tepid water immediately after treatment and a total of eight glasses in the
following eight hours.
• Use only professional skin care products recommended by your esthetician or physician.
• Notify your esthetician or physician of ANY concerns.
• Do not use tanning beds, and avoid sun exposure as much as possible. Apply sunscreen DAILY and
for added protection, use GlyMed Plus® Photo-Age Skin Shield Make-up with sun protection.
Steps to remember post-peel:
• Avoid all sun exposure.
• Avoid exercise and sweating for 48 to 72 hours.
• Avoid having the shower spray directly on the face.
• Do not pick, rub, or unnecessarily touch the face.
• Minimize facial expression.
• Sleep on back.
• Shampoo with head tilted backward to avoid shampoo on skin.
I have read the post care instructions and agree to adhere to them.
I herby give my voluntary consent and authorization for treatment and release the above named provider, its employees, associates and subsidiaries and GlyMed Plus® LLC. I release its employees, associates and subsidiaries, from any claims expressed or implied that I have or may have in the future, in connection with this treatment regardless of result. By signing, I am stating I fully understand the above and that the treatment had been explained to me in detail.
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Chemical Peel

Tell me about your skin.

Skin Self-Analysis

Medical History

Female Clients

Male Clients