CLINICARE SKIN PEEL FORM

Name

First NameLast Name
Prior to receiving treatment, please reveal any conditions that may have an effect on this treatment. If you are unsure of any details including personal requirements and potential complications, please discuss with your practitioner.
Are you currently under going any doctor or specialist care?Do you take over the counter or prescrption medication?Do you have any current or serious medical illnesses?DiabetesHeart disease/anginaEpilespyHepatitisBlood disordersCancerPsoriasis / EczemaLupusRheumatoid ArthiritisWeakened immune systemAny known allergiesFacial cold soresAcneRosaceaHerbesWarts/ molesContact DermatitisInflammatory skin diseasesDo you have / have had any form of skin cancerAre you currently receiving chemotherapy or radiotherapyHave you taken oral retionols for acne such as oral retinoids ( Roaccutuane) or Benzoyl Peroxide in the last 6 months.Are you used topical retinoids ( Viatmin A, Retinol in the last week?Are you taking steriods or anti cagulants on a daily basisDo you have keloid scarringHave you used any exfoliants or products containing AHA's, BHA's such as Glycolic, Lactic and fruit acids and Hydroquinone in the last week?Have you recently had facial surgery or aesthetic treatment?Have you had any other skin peels, laser, dermaplanning, micro-needling or other facial treatments recently including Botox and Filler.Have you waxed, had electrolysis or used hair removal creams in the last week?Recent sun burn, wind burn, cuts or abrasions.Pregnant or Breast feeding
None of the above applies
Give details if you ticked any:
Please list what skin care products you are using at home.
How would you class your skin type based on the Fitzpatrick scale below:
Type 1Type 2Type 3Type 4Type 5Type 6
Give details:
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Please read the following statements.

The skin peel procedure is typically used to improve the clinical appearance of the skin. A chemical solution is applied to remove the upper layer of the epidermis to encourage the regeneration and rejuvenation of new skin cells. After the skin peel, the skin may experience: Redness and flushing (any redness should decrease over the following 1-8 hours) Dryness, tightening Tingling, itching

Stinging Light peeling These temporary skin responses will typically subside within hours and many people are able to return to their normal activities the same or next day. Some people may react differently and may experience these reactions for longer. However, these reactions are temporary and usually resolve within 3-7 days as the skin returns to normal. Although rare, there is a small risk of side effects including swelling, blistering and crusting or for a mild acne breakout. In severe cases infection and ulceration may result, although this is not expected to occur due to the sterility of the procedure and the minimally invasive nature of the peel. There is a small risk that skin discolouration (hyperpigmentation) of the skin can occur after the procedure, although this is not normally expected due to the superficial type of peel used. Failure to follow the advice detailed below can increase this

Post treatment advice: The skin may peel or flake but refrain from touching, picking or pulling at any loose skin as this may compromise results. The skin can be cleansed with a gentle cleanser with warm / tepid water but the use of soap should be avoided until the skin normalises. Do not scrub. Pat to dry only. Avoid the use of benzoyl peroxide or glycolic acid facial skin products during the healing process. Avoid facial products containing fragrance for 5-7 days after treatment as these may irritate the skin. Avoid the use of exfoliants, further peeling agents, retinoids, retinols and vitamin A products for 5-7 days after

Refrain from saunas, sunbed, steam baths and hot showers for 24 hours. Avoid high impact aerobic exercise or vigorous physical activity for 24 hours after treatment. Avoid intensive sun exposure, tanning booths or extreme weather conditions for 2 weeks. Use daily sunscreen protection with a minimum of 30 SPF for at least 2 weeks after treatment. Avoid electrolysis, depilatory creams, waxing and laser hair removal for a minimum of 7 days after treatment. Avoid strong chlorinated water (swimming or cleaning) for approximately 14 days. Use of an intensive moisturiser is advised for at least a week as skin may feel drier or tighter after treatment. Mineral make-up can be applied once skin has settled. Any concerns should be reported to your practitioner as soon as possible.
I confirm that I understand the risks and conditions associated with a Skin Peel treatment and that it is an elective cosmetic procedure. I understand the post treatment advice and will follow this.
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I confirm that I understand the risks and conditions accociated with this treatment and that it is an elective medical- cosmetic treatment.

I confirm that the medical history and medication details that I have supplied are complete and correct and that there is no

other medical information I need to disclose.

I understand that withholding any medical information may be detrimental to my health and safety during the treatment in which I agree to undertake. If there is any change in my medical history, it is my responsibility to advise the practitioner before further treatments are carried out.

I understand that there are certain contraindications that would preclude me from receiving treatment including an active bacterial, viral, fungal, or herpetic infection, open wounds, a history of drugs with photosensitizing potential, preexisting inflammatory dermatoses (eg, psoriasis, atopic dermatitis, pemphigus), facial cancers, a history of abnormal scarring, keloids, atrophic skin, or isotretinoin use in the last 12 months. I understand there may be some degree of discomfort during and after the treatment but agree to inform the pratitioner immediately if I have any concerns. I confirm that I understand the risks and conditions associated with the treatment. These have been fully explained to me and I have had the opportunity to ask any questions and these have been answered to my satisfaction. Development of any reactions must be reported to the practitioner as soon as possible. I accept and understand that there are no written, implied, or verbal guarantees as to the anticipated results of this treatment and that the effects of treatment will vary with some patients than with others and that the goal of this treatment is improvement, not perfection.

I may require a series of treatments, normally with at least 2-4 weeks between procedures, to achieve the maximum

I have been given post treatment advice and I understand and agree to follow all the care instructions carefully to minimise the risk of side effects.

I confirm that I have been allowed sufficient time to make a carefully considered decision.
Taking photos is very helpful to see progress within the skin, please tick if you are happy for any of the following.

Photos for educational use.Social MediaMyself onlyI would not like any photos.
I have read the above consent, and I confirm that by signing this form I consent to fundergo treatment and I takeresponsibility to inform of any change in my medical history.

Yes
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