Chemical Peel Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral retinoid treatments such as: tretinoin, Retin-A®, isotretinoin, Accutane®, Differin®, Tazorac®, Avage®, EpiDuo®, or Ziana®.

I understand there may be some degree of discomfort, such as stinging, pin-prickling sensation, heat, or tightness.*

YesNo

I understand 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.*

YesNo

I understand I may or may not actually peel and that each case is individual. I understand that the amount of peeling does not correlate with degree of improvement.*

YesNo

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.*

YesNo

I understand that to achieve maximum results, I may need several treatments.*

YesNo

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the physician/clinician who performed the treatment.*

YesNo

I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment, and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging.

I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum SPF of 30
is mandatory.

I have not had any other chemical peel of any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location.

I understand that I should follow my clinician’s recommendations for post-procedure skincare to minimize side effects and maximize results.

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-peel care instructions as I am directed.

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

I consent and authorize Michelle Nguyen, Boss Beauty by Michelle Nguyen LLC, Licensed Esthetician, to perform one or more chemical peels on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Boss Beauty by Michelle Nguyen LLC and Michelle Nguyen from all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the future as well.

Signature*