• Clover Beauty LLC

    Treatment Consent

  • Chemical Peel Consent

    Please initial to indicate your acknowledgment

  • A 60 Minute Facial is required prior to recieving any chemical peel services.

  • I understand my esthetician will take every precaution to minimize or eliminate negative results such as blisters, sores, or other reactions. I understand that, very rarely, permanent damage occurs*
  • I have given an accurate account of any over the counter or prescription medications that I use regularly, and I am not currently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, ect.*
  • I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels and skin treatments that I have not disclosed to my esthetician*
  • I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment*
  • I have disclosed all known allergies in my previously filled out general consent form*

  • By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive a chemical peel treatment from my esthetician/Clover Beauty LLC. I understand that this agreement is binding and will remain in effect for all immediate and future services/procedures received at Clover Beauty LLC. I certify that I have read and understand this entire consent form and I and agree to the information provided in this form. I certify that I am at least 18 years of age and give my consent to treatment. The treatments I receive here are voluntary and I release Clover Beauty LLC and/or the esthetician from liability and assume full responsibility thereof.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: