Chemical_Peel_Consent

Chemical Peel Intake Form
General Information
Name*

First NameLast Name
Date of Birth*

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Date
Address*

Street Address

Street Address Line 2

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Phone#*
Email*
example@example.com
Occupation
Emergency Contact Name
Phone#
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Consents
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
By signing below I knowingly and willingly consent to release any and all liability for the unintent ional exposure or harm due to COVID- I9.

By signing below, I agree to the following:
I have completed t his form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any cond ition(s) that would make the requested treatment unsuitable. I will inform the technician of any d iscomfort I may experience at any time during my treatment to allow them to adjust
accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries. losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
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Chemical Peel Pre-Procedure Instructions
To maximize the desired outcome of your chemical peel, we recommend you follow the
following pre-procedure instructions prior to your scheduled treatment:

General Home Care Regimen Advice:
- Incorporate a Retinoid into your home care regimen.
- Use a physical sunscreen with at least an SPF 30+ every day
Three weeks Before Appointment
• No tanning

Two Weeks Before Appointment
• No IPL or Laser Hair Removal

One Week Before Appointment:
- Stop use of Retinoid products (Retin A, Tri Retinol Complex, etc.)
- Discontinue the use of any benzoyl peroxide products or any other product that can
  cause dryness. redness. or irritation.
- No facial waxing
- No filler
- No Botox

Chemical Peel Post-Procedure Instructions
To maximize the desired outcome of your chemical peel, we recommend you follow the following post- procedure instructions following your scheduled treatment:
DO
- Pull your hair back and away from your face to prevent you from touching your face.
- Treat skin gently. Wash your face only with a gentle cleanser and cool water. Use your
  hands only and pat dry no earlier than 4 hours after the peel.
- Gently apply a thin layer of moisturizer all over the skin multiple times throughout the
  day, as needed.
- Use a sunscreen (SPF 30+) to protect your delicate facial sk
Avoid the following to prevent undesired results:
- Touching. picking, or scratching the treated area
- Hot baths or showers (cool or lukewarm water only)
- saunas, hot tubs, pools, or steam rooms
- Massage or friction in the treated area
- Rubbing your skin dry
- Strenuous exercise and activities that cause you to sweat
- Tanning (sunbathing, sunbeds, or fake tans)
- Exfoliating the treated area
- Applying products to the treated area (including make-up, lotions, soaps, powders,
  perfumes. harsh cleaning products. and self-tanning products)
- Direct sun exposure
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Chemical Peel Intake Form

Medical History

Skin Care History

Important Information

Cavitation Consent Form

Consents

Chemical Peel Pre-Procedure Instructions

Chemical Peel Post-Procedure Instructions