Chemical Peel Intake Form

Client Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth*

Date

Occupation*

How did you hear about us?*

Are you pregnant, breastfeed, or nursing? (Female)*

YesNo

Do you have any allergies? If yes, what?*

Are you currently taking any medications? If yes, please list them below:*

Are you currently using Accutane? If yes, how long?*

Have you been under the care of a Dermatologist in the past year? If yes, for what?*

Have you received Botox injections in the past six months?*

YesNo

In the past 30 days have you received any Chemical Peels, Microdermabrasion or Laser treatments?*

YesNo

Do you currently use Retin-A®, Differin®, Tazorac® or Vitamin-A (Retinol)? (If so, discontinue use 7-10 days pre and post chemical peel)*

YesNo

Do you currently have a sunburn, wind-burn?*

YesNo

Are you in the habit of going to tanning booths?*

YesNo

Do you currently receive waxing services on your face? (Discontinue 7 days pre and post chemical peel)*

YesNo

Have you ever received a chemical peel or any procedure with a medical device? (Chemical peels should follow injections after 2-5 days)*

YesNo

Have you recently had facial surgery or laser resurfacing?*

YesNo

Do you participate in sports, aerobic exercise, or work out regularly?*

YesNo

What skincare products are you currently using? (list brand where known)*

What is your skin type?*

NormalDryOilyCombination

What concerns do you have for your skin? (select all that apply)*

Do you have any additional information you would like to let your Esthetician know before your scheduled appointment?

Prior to receiving this treatment, I have been candid about revealing any condition that may contraindicate this procedure, such as: pregnancy (if so, consult your physician prior), recent facial surgery/resurfacing, allergies, tendency to cold sores/fever blisters, use of Retin-A, Accutane, Differin, Retinol, or Tazorac.

I understand there may be some degree of discomfort (stinging, tingling, heat, tightness, pin-prickling sensation).

I understand that there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc. I understand that I may or may not peel, that each case is individual. I understand that to achieve maximum results I may need multiple treatments.

I agree to refrain from tanning bed for 14 days after treatment. I agree that extended direct sun exposure is prohibited while undergoing treatment with my esthetician. Daily use of sunscreen with a minimum of SPF 15 is required.

I have not received any chemical peels 14 days prior to receving this treatment. I agree that I cannot have another treatment within the 14 days of receiving this treatment, whether it is at this location or another location.

I have completed this form to the best of my ability and knowledge and agree to inform the esthetician of any changes in the above information. I understand that withholding information or providing misinformation may result in contraindications or irritation to the skin from treatments received. The treatments I receive here at Luxe Skin Studio are voluntary and I release this skin care professional from liability and assume full responsibility thereof.

Client Signature*

If under 18, Parent/Guardian Name

First NameLast Name

Parent/Guardian Signature

Chemical Peel Intake Form

Client Information

Medical / History Data

Authorization