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Informed Client Consent: Chemical Peels

INFORMED CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: Chemical Peels 


I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved. 


Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. 


I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. 


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. 


I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense. 


I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes. 


I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. 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 been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today. 

Client Signature:

Date: August 1, 2026

Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin). 


I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense.  


I understand that I should not have a chemical treatment 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. 


I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that 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, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results. 


I understand that results are not guaranteed and 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 conditions. 


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


I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist.


I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. 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 the procedure and accept the risks. I 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. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.

I understand that aerobic exercise or vigorous physical activity should be avoided for the first 48 hours.

Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure and tanning beds). If some sun exposure cannot be avoided, first apply sunscreen with an SPF 30 or greater. Sunscreen should become a part of your daily skin care regimen as your skin will become more sensitive to the sun as a result of this treatment. 

I understand that I cannot apply any type of glycolic acid or exfoliation products as this can severely damage or irritate the skin during the entire healing process.

I understand that I cannot peel, rub, or scratch the skin at anytime, whatsoever. This can cause damage and compromise the results as well as possibly cause severe scarring. 

By signing below, I verify that I have read and understand the above statements and agree to them. 

Client's Signature:

Today's Date: August 1, 2026


POLICY CONSENT

Rescheduling & Cancellations

You are responsible for rescheduling or canceling your appointment via the booking app link sent to you by text. If you are experiencing technical issues, please text Jacky at 719-297-1447.

No charges for rescheduling if done 48 hours prior to your appointment time. 


Children Policy

To fully enjoy your experience, please leave children at home unless they are being serviced. Enjoy your self-care! 


Consent Forms

After your booking is confirmed, please visit the main page of my website and click the menu bar (top right-hand corner). Select the drop-down menu, proceed to select the consent form for your treatment. Forms must be completed at least 6-8 hours prior to your treatment time. 


Arrival Instructions

Upon arrival, find Jacky’s doorbell by the reception desk. Please have a seat and wait for your name to be called. You are welcome to use the restrooms within the facility. 


Conduct Policy

Disrespectful behavior will not be tolerated. You may be dropped as a future client if Jacky feels uncomfortable or unsafe. 


Tardiness

Appointments are subject to rescheduling and additional fees if you are more than 10 minutes late. 


Cancellation Fees

  • Late cancellation (less than 48 hours): 50% of service total
  • Same-day rescheduling/cancellation: 50% of service total
  • No-show/no-call: 100% of service total

No-shows or no-calls may result in being dropped as a future client. 


Refunds & Satisfaction Policy

Please note that no refunds will be issued for services rendered. However, your satisfaction is very important to me. If you are dissatisfied with your service, please contact me directly as soon as possible. I will work with you to address your concerns and ensure you are comfortable with your results. I am committed to providing an excellent experience and will make every effort to resolve any issues.


Retail Item Policy

All retail sales are final and non-refundable. However, if you are not completely satisfied with your purchase, I am happy to offer an even exchange for another product of equal value. Please contact Jacky within 7 days of purchase to initiate the exchange. Items must be unused, unopened, and in original condition to qualify for an exchange. 



Beauty Realm LLC
(719) 297-1447

First Client's Name
First Name*
Middle Name
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
First Client's Signature*
Second Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Third Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Fourth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Fifth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Sixth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Seventh Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Eighth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Ninth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Tenth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
No
Yes
Additional Information
Technician/Esthetician Performing Procedure:*
ID of Client or of Parent or Guardian (if Client is underage)
  
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Are you currently using any prescription or over-the-counter medications? *
No
Yes
If yes, please list:
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?*
No
Yes
If yes, please indicate what and when last used:
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? *
No
Yes
List any allergies you have:
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? *
No
Yes
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*
No
Yes
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? *
No
Yes
Are you currently pregnant or breastfeeding? *
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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