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Chemical Peel Consent Form

CHEMICAL PEEL TREATMENT PURPOSE: A chemical peel is a mid-deep level designed to improve the texture and appearance of your skin.

CLIENTS WHO SHOULD NOT BE TREATED: A chemical peel SHOULD NOT be used on clients with active cold sores or warts, skin with open wounds, sunburns, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated. Inform your esthetician if you have any history of herpes simplex. You should also not have a Chemical Peel if you have a history of allergies, rashes, or other skin reactions, or may be sensitive to any of the components of this treatment. A Chemical Peel should not be performed on clients with an allergy to salicylates (i.e., aspirin). A peel is also not recommended if you have taken Accutane® within the past year, or received chemotherapy or radiation therapy. Chemical Peel should not be administrated to pregnant or breast feeding (lactating) women. 

ONE WEEK BEFORE YOUR CHEMICAL PEEL: Avoid these products and /or procedures in area(s) treated: • Electrolysis • Waxing • Depilatory Creams • Laser Hair Removal • Clients who have had medical cosmetic facial treatments or procedures (e.g. laser therapy, surgical procedures, cosmetic filler, microdermabrasion, etc.) should wait until  skin sensitivity completely resolves before having a Chemical Peel • Clients who have had BOTOX® injections should wait until full effect of their treatment is seen before receiving a Chemical Peel. 

THREE DAYS BEFORE YOUR CHEMICAL PEEL: Avoid these products and /or procedures: • Retin-A®, Renova®, Differin®, Tazorac® • Any products containing retinol, AHA or BHA, or benzyol peroxide • Any exfoliating products that may be drying or irritating

Note:  the use of these products/treatments prior to your peel may increase skin sensitivity and cause stronger reactions. 

AFTER YOUR CHEMICAL PEEL: It is crucial to the health of your skin and the success of your peel that these guidelines be followed:

1. It is imperative that you use a sunscreen with an SPF of at least 20 and avoid direct sunlight for at least 1 week. 

2. Clients with hypersensitivity to the sun should take extra precautions to guard against exposure immediately following the procedure as they may be more sensitive following the peel.

3. Because of the superficial nature of a chemical peel, clients should expect to see visible peeling. Occasionally, some clients may have very minor flaking 3-4 days after the procedure.

4. Skin may appear red for about one hour after treatment. If neck and décolletage area are treated, the redness might last slightly longer.

5. Skin should look normal the next day.

6. Apply a light moisturizer as often as needed to relieve dryness and tightness.

7. You may resume the regular use of Retin-A®, alpha-hydroxy acid (AHA) products or bleaching creams ONLY after the peeling process is complete or after 4-5 days.

ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR CHEMICAL PEEL: It is common and expected that your skin will be red and possibly itchy and/or irritated. It is also possible that other adverse experiences (side effects) may occur. Although rare, the following adverse experiences have been reported by clients after having a chemical peel: edema, stinging and burning, dryness and erythema. 

I understand that the Chemical Peel treatment is not an exact science and the degree of improvement is variable. 

 

I understand that occasionally there is no visible improvement and another form of treatment may be required. 

I do not have any of the conditions described in the “Clients Who Should Not Be Treated” section. 

By my signature below, I acknowledge that I have read this Chemical Peel informed Consent form and understand it. I have been given the opportunity to ask questions and may question have been answered to my satisfaction. I have been adequately informed of the risks and benefits of this treatment and wish to proceed.

May 22, 2019

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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