VANITIES chemical peel

Informed Client Consent: Chemical Peels

Name

Address

Street Address Line 2

CityState

Zip

Phone

Email Address

example@example.com

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

YesNo

If yes, please indicate what and when last used:

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?

YesNo

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:

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?

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 there are risks and complications associated with having a chemical peel andthat, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skinSignature

I understand that this chemical procedure is expected to make the skin feel uncomfortable while being 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 concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense. Continued a Associated Skin Care Professionals member

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

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

I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen. I understand and agree to follow the home-care instructions and recommendations provided by my skin therapists. I understand that I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, 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 be required. The rate of improvement of my skin depends on my age, skin type and condition, of sun/ environmental damage, pigmentation levels, or acne conditions.

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

I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my 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 and am over the age of 18 years old. I give permission to my skin therapist to perform the treatment we have discussed and will hold him/her and his/ her staff harmless from any that may result from this treatment. I understand the procedure and accept the risks. I have 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, 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 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

Skin Therapist

Date

VANITIES BY JAY. DEAUTY AND AESTHETICS

Post-treatment/Home Care-Chemical Peels Aerobic exercise or vigorous physical activity should be avoided for the first 48 hours. Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure and tanning beds If some sun exposure cannot be avoided, first apply sunscreen with an SPF of 30 or greater. Sunscreen (with at least a SPF of 15) should become a part of your daily skin care regimen as your skin will become more sensitive to the sun as a result of this

Cleanse your face with water or a mild soap substitute such as Gently moisturize your face using Do NOT apply any type of glycolic acid or exfoliation products as this can severely damage or irritate the skin during the entire healing process. DO NOT peel, rub, or scratch your skin at any time, whatsoever. This WILL cause damage and compromise your results as well as possibly cause severe scarring. Ifyou experience painful areas of the face, contact your skin care therapist immediately, especially if you are prone to cold sores. Any blisters that form will need to be reported immediately. In the event that you may have additional questions or concerns regarding your treatment or suggested home product/post-treatment care, you must consult your therapist immediately.

Additional instructions

Client Name (printed)

Client Name (signature)

Date

Esthetician

Type a question

Type option 1Type option 2Type option 3Type option 4

Date

JAY BY BEAUTY AND AESTHETICS

VANITIES -BY JAY- DEAUTY AND AESTHETICS