CHEMICAL PEEL CONSENT FORM

CHEMICAL PEEL CONSENT FORM

Thank you for Choosing EN Signature Brows and Beauty Studio for your services. We love to give our clients the best quality service. Please fill out the form below.
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email*
example@example.com
To the Guest:

You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment
I voluntarily request that Elizaveta Neginskaya perform the Peel procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin.*
Initial
Peels, despite their high levels of efficacy and safety, are not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.*
Initial
I understand complications can include white heads, cold sores, infection, scarring, numbness and permanent discoloration, particularly in people with dark skin.*

Yes, I Understand
It is important to use sun screen of SPF 25 or greater when exposed to the sun.*

Yes, I agree
No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.**

Yes, I agreeNo
I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
Initial
I give Elizaveta Neginskaya permission to take, publish and reproduce photographs of me, my face, and/or my eye area, both before and/or after the procedure for advertising and other purposes.*

Yes, I agreeNo
I am 18 years or older

Yes, I am 18 years old or olderNo, I am not 18 years old. I have a parental and/or guardian signature for consent.
I am not 18 years old. I have a Parental and/or guardians signature for consent. By signing you understand all possible risks of this service.

Clear
Print Parental/Guardians name:
first and last name
REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for yourself or for another individual are absolutely non-refundable.This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.*

Clear
I give my consent to Elizaveta Neginskaya for facial services. My signature below acknowledges that I have not knowingly withheld or falsified my above personal information and I will adhere to all the aforementioned statements that I have initialed.*

Clear
Today's Date*

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Date
Please provide an email for follow up care.*
example@example.com
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