Chemical Peel Consent Form printable pdf download

Chemical Peel Consent Form

I, _______________________________, have read the below information and initialed each section to indicate that I fully

understand what to expect. If I have any questions or concerns, I will address these with my skin therapist. I give permission to my

skin therapist, ________________________, to perform the chemical treatment we have discussed and will hold him/her and

his/her staff harmless from any liability that may result from this treatment. I understand my skin therapist will take every precaution

to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I do understand that,

very rarely, permanent damage occurs. I have given an accurate account of any over-the-counter or prescription medications that I

use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or

tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin

treatments that I have not disclosed to my skin therapist. I am not ingesting or using topically any other over-the-counter product or

prescription medication/agent that has not been disclosed to my skin therapist. I am not presently pregnant or lactating and I am

over the age of eighteen (18). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin.

I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring,

diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive

outcome of this treatment. ___________

Client Initials

I understand that I should not have a chemical peel 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.

____________

Client Initials

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

Client Initials

My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one

application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of

sun/environmental damage, pigmentation levels, or acne condition. ____________

Client Initials

I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree to inform the skin

professional immediately if I have concerns or am overly uncomfortable during treatment or after I return home. ____________

Client Initials

I agree that I am willing to follow recommendations by my therapist for home care. 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 and

avoiding the sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by my

therapist and I acknowledge that I have been informed of the possible negative reactions (intense erythema, welts, scabs) and the

expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have

additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my therapist

immediately. ____________

Client Initials

I understand the potential risks and complications and have chosen 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 the above paragraphs and that

I have had sufficient opportunity for discussion to have any questions answered.

Client Name (printed) _________________________________________________________________________________

Client Name (signature) _______________________________________________Date_____________________________

Chemical Peel Consent Form