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Metropolitan Day Spa

 

Chemical Peel Consent Form

PURPOSE: Helps to improve the texture and appearance of your skin.

 

CLIENTS WHO SHOULD NOT BE TREATED:

• Clients with active cold sores or warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated. Inform the aesthetician if you have any history of herpes simplex.

• Clients with a history of allergies (especially allergies to salicylates like aspirin), rashes, or other skin reactions, or those who may be sensitive to any of the components in this treatment.

• Clients who have taken Accutane within the last year.

• Clients who are pregnant or nursing.

• Clients who have recently received chemotherapy or radiation therapy.

• Clients with vitiligo.

• Clients with a history of an autoimmune disease (such as rheumatoid arthritis, psoriasis, lupus, multiple sclerosis, etc) or any condition that may weaken their immune system.

NOTE* Clients who have had medical cosmetic facial treatments or procedures (i.e, laser therapy, surgical procedures, cosmetic filler, microdermabrasion, etc.) should wait until skin sensitivity completely resolves before receiving a SkinMedica Chemical Peel.

 

ONE WEEK BEFORE YOUR SKINMEDICA CHEMICAL PEEL, AVOID THESE PRODUCTS AND/OR PROCEDURES:

• Electrolysis

• Waxing

• Depilatory creams

• Laser Hair Removal

 

THREE DAYS BEFORE YOUR SKINMEDICA CHEMICAL PEEL, AVOID THESE PRODUCTS AND/OR PROCEDURES:

• Retin-A, Renova, Differin, Tazorac • Any products containing retinol, alpha-hydroxy acid (AHA) or beta-hydroxy acid (BHA), or benzoyl peroxide

• Any exfoliating products that may be drying or irritating

 

ADVERSE EXPERIENCES THAT MAY OCCUR AFTER YOUR SKINMEDICA CHEMICAL PEEL

It is common and expected that your skin will be red, dry, possibly itchy and/or irritated. It is also possible that other adverse experiences may occur. Although rare, the following adverse experiences have been reported by patients: Skin breakout of acne, rash, swelling, redness and burning

 

Consent Agreement

I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability on the provider and Metropolitan Day Spa should I fail to do so.

My questions regarding the treatment have been answered satisfactorily.  I understand the treatment and accept any risks. I hereby release the provider and Metropolitan Day Spa from all liabilities associated with the above indicated treatment.    

I agree that this consent supersedes any previous verbal or written disclosures.  This consent is valid for all of my facial treatments in the future as well.

Today's Date: February 5, 2025

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA

How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes

If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes

If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery

If items checked above, please list and when
Do you have permanent make up?*
No
Yes
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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