Chemical Peel Consent Form

I hereby consent to an Advanced Treatment of a Chemical Peel to be applied to my face. The procedure, benefits, and risks of a Chemical Peel has been explained to me.

I understand that this treatment is a program. It does require a series in order to achieve results. I agree to use a Pre-Peel kit and the recommended Skincare products by my Aesthetician.

I understand that I might feel a spicy sensation that would last for 1-3 minutes upon application of the chemical to my skin. I understand that after a few days, the area where the chemical peel was applied may darken, become flaky and/or shall become glossy or shiny.

I understand that there are no guarantees that the desired result would be achieved.

I understand that complications may occur, although this is rare. In case such happens, I will contact my doctor. Complications may appear as, allergic reactions due to medications or with the chemical peel or both; Keloids or thick scars; Increased or decreased pigmentation; Sensitivity to the wind or sun.

Use of photographs:

I consent to have my photographs taken before, during, and after my treatment. I understand that using these materials will not fully reveal my identity. The purpose of this is for education and possible marketing.I do not consent to have my photographs taken before, during, and after my treatment.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Signature*

Date*

Date