Chemical Peel Consent Form printable pdf download

Chemical Peel Consent Form

Patient #___________

A chemical peel can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce

pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance

of hyperpigmentation. Layers of product are applied based on your unique skin composition and needs. Multiple

treatments are required in order to obtain optimal results spaced 2-6 weeks apart. Due to variables such as age,

condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you

acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.

Contraindications:

1. Pregnancy/Lactating

2. Herpes Simplex (cold sores or fever blisters). An anti-viral medication may be necessary prior to treatment.

3. Extensive sun or tanning 3 days prior and 3 days post treatment.

4. Accutane in the past 6 months to 1 year.

5. Topical retinol products in the past 2 weeks.

6. Waxing of area to be treated in the past 7 days.

7. Any other chemical peel within 14 days of the treatment.

8. Skin must be healthy and intact.

9. An allergy to aspirin.

I am aware of the following risks/complications that may occur:

1. Mild to moderate discomfort or pain

2. Slight redness or swelling

3. Sun sensitivity

4. Skin sensitivity

5. Pigment changes

6. Scarring

7. Allergic reaction

8. Bacterial infection

I understand that the treatment may involve risks of complication or injury from both known and unknown causes,

and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may

have a bearing on this procedure.

I consent and authorize Jennifer Nunez, RN, BSN to perform one or more chemical peels on me. I certify that I

have read this entire informed consent and I understand and agree to the information provided in the form. My

questions regarding the procedure have been answered satisfactorily. I hereby release Jennifer Nunez and LCI from

all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the

future as well.

Signature_______________________________________

Date_____________________

RN Signature____________________________________

Date_____________________

Chemical Peel Consent Form