Chemical Peel Intake

Client Name

DOB

Phone #

Address

Street Address Line 2

CityState

Zip

Email

example@example.com

How did you hear about us?

Are you pregnant or lactating?

YesNo

Do you have any permanent makeup?

YesNo

Do you currently have a sunburn, windburn, acne flareup or other skin irritation?

YesNo

Do you use hair removal products or receive hair removal treatments (depilatories, sugaring. waxing, laser hair removal)?

YesNo

Do you currently or regularly use ORAL or TOPICAL medications (Retin-A, Renova, Differin, Tazorac, Benzoyl Peroxide, or Other)?

YesNo

Have you ever received a chemical peel?

YesNo

Have you had any type of resurfacing or other procedure using a medical device on your face? (lasers, radio-frequency, microneedling, etc.)

YesNo

Do you receive Botox, Filler or Other?

YesNo

Do you develop cold sores or fever blisters?

YesNo

Are you pregnant or lactating?

YesNo

Do you have any allergies or sensitivities to products?

YesNo

Are you currently taking or have you taken ACCUTANE within the last year?

YesNo

Do you consent to any photos/videos to be taken during/before/after your service for purposes of educational material, marketing, promotions, etc?

YesNo

Client acknowledges and understands that a chemical peel involves the use of chemical agents to exfoliate the outer layers of skin, which can result in skin irritation, redness, swelling, blistering (in rare cases), peeling, and other potential side effects. The Client also understands that individual reactions to chemical peels may vary, and that results may not be guaranteed.

YesNo

Client hereby releases, waives, discharges, and holds harmless the Provider, the business Lush Skin Studio, its employees, agents, and affiliates from any and all liability, claims, demands, or causes of action that may arise out of or in connection with the chemical peel treatment, including but not limited to any complications, injuries, or adverse reactions that may occur.

YesNo

Client understands that results of the chemical peel treatment can vary depending on skin type, health, and post-treatment care. While Provider will take all reasonable precautions, there is no guarantee of specific outcomes or results from the procedure.

YesNo

By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my esthetician of any changes to the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that do not have any condition(s) that would make the requested treatment unsuitable. I will inform my esthetician of any discomfort Imay experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my esthetician and "Lush Skin Studio" for any injury or damages incurred due to my misrepresentationof my health history.

Client Signature

Date

Chemical Peel Intake

LUSH SKIN STUDIO

CLIENT INFORMATION