3141 E Broad St Suite 303 Room 114, Mansfield, TX 76063
(682) 213-0798
lealux.glossgenius.com
Chemical Peel Consent Form
Client Details
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Medical Information
Do you have any of the following conditions? They may determine that you are not suitable for chemical peel.
Taking Accutane within the past six months
*
Yes
No
Active herpes simplex (cold sores)
*
Yes
No
Facial warts
*
Yes
No
Currently pregnant/ think you might be pregnant / trying to become pregnant
*
Yes
No
Keloid or hypertrophic scars
*
Yes
No
History of sun allergies
*
Yes
No
Prior bad reaction to a peel
*
Yes
No
Recent radiation treatment for cancer
*
Yes
No
Sunburn or significant sun exposure in the last week
*
Yes
No
Surgery or cryosurgery within the last month to the area that you plan to have peeled
*
Yes
No
Allergic to Resorcinol
*
Yes
No
Allergies to salicylic acids
*
Yes
No
Blood vessel disease
*
Yes
No
Diabetes
*
Yes
No
Inflammation / irritation / infection of the skin
*
Yes
No
Influenza
*
Yes
No
Varicella (chicken pox)
*
Yes
No
Kidney or liver disease
*
Yes
No
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Pre-Treatment Instructions
Do not apply Retin-A, Renova, Tazorac, and/or Differin 2 weeks prior to, and for 2 weeks after your peel, to the treatment area.
Do not sun tan or use the tanning bed 4 weeks prior to, and for 4 weeks after your treatment.
Stop any type of depilatory treatments (waxing, depilatory creams) to the area of treatment, 2 weeks prior to, and for 2 weeks after your peel.
Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of treatment, 4 weeks before and for 4 weeks after your peel.
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Post-Treatment Instructions
When cleansing, do not scrub. Use a gentle cleanser as directed by your skincare specialist.
With any peel, your skin may start to peel 1-3 days after the peel and continue to peel for up to 5 more days; however, it is also possible your skin may not peel at all.
Do not peel, pick or scratch the treated area, as this may result in scarring.
Apply polysporin, bacitracin or Vaseline to dry flaky areas or as directed by your skincare specialist.
Do not have any other facial treatments for at least 2 weeks after your peel or until the skin is smooth and back to normal.
If given a cortisone cream by your skincare specialist, please apply it 1-3 times per day to red irritated areas or as directed. Follow any additional and all instructions given to you by your skincare specialist.
Always wear your sunscreen; apply a sunscreen with SPF 30 every morning.
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Consent
Please check each box to show your understanding and agreement.
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Signature
This agreement will remain in effect for this procedure and all future chemical peel procedures. I will alert the skincare specialist if there are any future changes to my medical history. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the chemical peel procedure.
Signature
*
A copy of this signed agreement will be emailed to you.
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