Chemical Peel Client Intake Form

Welcome to The Complexion Cottage!

Thank you for trusting us with your skin.

Please complete this required form PRIOR to your appointment. Failure to do so may impact your time in treatment.

To ensure your chemical peel is safe, effective, and tailored to your skin’s needs, it’s important that we have current and accurate information about any medications, treatments, allergies, or health conditions.

All information provided is strictly confidential and used solely for treatment purposes.

Please allow 5-10 minutes to complete this form.

Thank you!

Today's Date

Date

Full Name

First NameLast Name

Date of birth

Date

Email Address

example@example.com

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Emergency Contact

What are your main skin concerns? (check all that apply)

How would you describe your skin type?

Which best describes how your skin reacts to sun exposure? If unsure, choose the option that most closely matches your experience.

Have you used any of the following in the past 7 days? This is important to ensure that your peel can be effective and safe.

If you answered YES, please provide additional relevant details below.

Please check any that apply:

If you answered YES to any of the conditions above, please provide additional relevant details below.

Do you have any known allergies to the ingredients listed below:

Have you had any of the following recently?

If you answered YES, please provide details below including dates of service.

Do you wear SPF daily?

Have you been tanning (beach or tanning bed) in the last 14 days?

Are you taking any medications or supplements you are currently taking?

What are you hoping to achieve from this treatment?

Is there anything else you would like your esthetician to know?

I confirm that the information provided above is accurate and complete.

I have reviewed and agree to the following clinic policies:

Chemical Peel Liability Waiver & Consent:

I, the undersigned client, consent to receive a chemical peel treatment provided by The Complexion Cottage. I understand that a chemical peel involves the application of chemical solutions to the skin in order to exfoliate and improve overall skin appearance, tone, and texture.

I acknowledge that chemical peels may produce varying results depending on my individual skin type, condition, and adherence to pre- and post-treatment instructions. I understand that multiple treatments may be necessary to achieve desired results and that no guarantees have been made regarding outcomes.

I understand that potential risks and side effects include, but are not limited to: redness, irritation, dryness, flaking, peeling, swelling, sensitivity, itching, temporary or prolonged hyperpigmentation or hypopigmentation, acne flare-ups, milia formation, infection, delayed healing, scarring (rare), and allergic reaction. I understand that deeper or more aggressive peels carry increased risk.

I acknowledge that sun exposure before or after treatment may increase the risk of complications, including pigmentation changes and impaired healing. I understand that I must avoid direct sun exposure and use a daily broad-spectrum sunscreen as directed following treatment.

I confirm that I have disclosed all relevant medical history, including but not limited to: use of isotretinoin (Accutane) within the past 6–12 months, use of topical retinoids, recent cosmetic procedures (including lasers, microneedling, or injectables), pregnancy or breastfeeding status, known allergies, medications, and any current or past skin conditions.

I understand that certain conditions may contraindicate treatment, including but not limited to: active infections, open wounds, cold sores, compromised skin barrier, recent sunburn, eczema or dermatitis flare, or known sensitivity to peel ingredients. I understand that my provider reserves the right to refuse or modify treatment if it is not in my best interest.

I agree to follow all pre-treatment and post-treatment instructions provided to me. I understand that failure to follow these instructions may increase the risk of adverse reactions and may impact my results.

I understand that I may withdraw my consent for treatment at any time. I further acknowledge that withdrawing consent during a treatment does not void or invalidate any previously signed authorizations, consents, or waivers related to services already rendered.

I understand that any false, misleading, or incomplete information provided by me, including in any written revocation request, may affect the safety and outcome of my treatment and may limit or release The Complexion Cottage from liability to the extent permitted by law.

I understand that my signature on this consent and waiver will remain valid and in effect for all future chemical peel treatments unless I revoke or update it in writing. I acknowledge that it is my responsibility to inform The Complexion Cottage of any changes to my medical history, medications, or skin condition prior to each appointment.

By signing below, I acknowledge that I have read, understood, and agree to the terms outlined above and voluntarily consent to treatment.

Client Signature ~ Consent to all policies

Date