Chemical Peel Consent Form
Name
First Name
Last Name
Date of birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
County
Postcode
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency contact
-
Area Code
Phone Number
I agree to receive marketing emails about special offers and promotions?
Yes
No
MEDICAL INFORMATION
Have you had any health problems, past or present? Please provide details.
Please list any medication, vitamins and supplements you currently take.
Have you taken isotretinoin within the last year?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Have you ever had a skin allergy?
Yes
No
If yes please specify:
Have you ever had a reaction to aspirin?
Yes
No
Do you have any metal implants, pacemaker or body piercings?
Yes
No
Do you wear contact lenses?
Yes
No
Have you had any cosmetic procedures, implants or injectables?
Yes
No
If yes please specify:
Do you suffer from cold sores?
Yes
No
YOUR SKIN:
What are your specific concerns with your skin?
What skincare products are you currently using?
Are you currently using any products containing the following ingredients?
Glycolic acid
Lactic acid
Retinol
Hydroxy acids (AHA/BHA)
Do you use sunscreen?
Yes
No
If yes, what SPF?
Have you received any chemical peels, microdermabrasion or resurfacing treatment in the last month?
Yes
No
Does your skin burn easily?
Yes
No
Do you have a tendency for redness, itching or sensitivity?
Yes
No
Do you wax, shave or use depilatories on areas to be treated?
Yes
No
Have you had any direct sun exposure in the last 48 hours?
Yes
No
CONSENT FOR TREATMENT
The nature and purpose of a chemical peel has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction prior to procedure.
I understand that possible side effects of the treatment area can include erythema (redness) and Edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to 7 days or longer. Irritation, itching and/or a mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.
I understand the results of this treatment may vary due to conditions such as age, condition of the skin, sun damage, climate etc.
I understand that any facial injections should be avoided 10 days prior to this treatment.
I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment and the use of daily sunblock protection is mandatory.
I am not using Retin A, or other retinol derivatives, products containing Alpha Hydroxy Acids (AHA) or Beta Hydroxy Acids (BHA) and have been off these products for at least 3 days prior to treatment.
I have been advised to avoid vigorous exercise, hot tubs and saunas for 72 hours following treatment.
I have been advised to refrain from wearing make-up for 24 hours following treatment.
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
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