CHEMICAL PEEL CONSENT FORM
DATE
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I understand my skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.
*
Please Select
AGREE
DISAGREE
I understand all clients experiences may vary and some clients may experience a delayed onset of these symptoms.
*
Please Select
AGREE
DISAGREE
I understand that I may have some peeling after my treatment which should subside within a week.
*
Please Select
AGREE
DISAGREE
I understand the skin is more susceptible to sunburn/sun damage after treatment. I will void excessive sun exposure and use a minimum of SPF 40 sunscreen.
*
Please Select
AGREE
DISAGREE
I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended regimen in the treated areas for minimum 2 weeks pre/post treatment.
*
Please Select
AGREE
DISAGREE
I understand photos may be taken before, during and after the treatment. Photos will only be used for education, promotion or advertising purposes.
*
Please Select
AGREE
DISAGREE
This consent form is valid for all future treatments and I will alert the staff if there are any future changes to my medical history.
*
Please Select
AGREE
DISAGREE
The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the hydrodermabrasion treatment by the staff at LUX BODY LAB.
*
Please Select
AGREE
DISAGREE
SIGNATURE
*
PARENTAL SIGNATURE (IF UNDER 18 YEARS OF AGE)
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