Chemical Peel Consent

Informed Client Consent: Chemical Peels

Name*

Address

Street Address Line 2

CityState

Zip

Phone*

Email Address*

example@example.com

Occupation:

How did you hear about us?

If referred, by who?

Are you currenty using any prescription or over the counter medications?

YesNoOther

If yes, please indicate what and when last used

Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A Acyclovir, or tranquilizers?

YesNoOther

Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment?

YesNoOther

List any allergies you have

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment

NoneOther

Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year?

YesNo

Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?

YesNo

Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated?

YesNo

Are you currently pregnant or breastfeeding?

YesNo

Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect.

I understand that this chemical procedure is expected to make the skin feel uncomfortable while applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or regarding my treatment or the suggested home product/post treatment care, I will consult my skin immediately. I understand that if I choose to consult a physician, that I do SO at my own expense.

I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and require regular use of sunscreen.

I understand and agree to follow the home care instructions and recommendations provided by my skin I understand that I will be responsible for following home regimens that can minimize or eliminate possible reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results.

I understand that results are not guaranteed and for maximum results, more than one application may required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/ environmental damage, pigmentation levels, or acne conditions.

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin

I understand that this agreement will remain in effect for this procedure and all future procedures conducted by skin therapist.

I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.

Client Name (Printed)

Client Name (Signature)

Date