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4860 N. Clark St, Chicago, IL 60640

773.675.1918

www.revivemassagechicago.com

Resurfacing Treatment (Chemical Peel)

I agree that all of the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment, in addition to home care products to receive the desired results. Results can not be guaranteed due to individual skin types and conditions.

What is a Chemical Peel?

A chemical peel is a technique used in aesthetics/skincare to improve the appearance of the skin on the face, neck or hands. A chemical solution is applied to the skin that causes the skin to suddenly exfoliate or shed, and eventually peel off. The new, regenerated skin is usually smoother, more even in color and less wrinkled than the old skin. Depending on the age, health, and current skin condition, a series of 3-6 peels at different depths is usually required to see any significant change/improvement. This series of peels is usually done over a 12 month period. The new skin is also temporarily more sensitive to the sun.

There are three basic types of chemical peels with different concentrations, and/or combinations:

Superficial or lunchtime peel: Alpha-Beta hydroxy acid (Glycolic,Lactic, Mandelic, Malic, Salicylic, Resorcinol), fruit enzymes or another mild acid is used to penetrate only the outer layer of skin to gently exfoliate it. The treatment is used to improve the appearance of mild skin discoloration and rough skin as well as to refresh the face, neck, chest or hands.

Medium peel:Glycolic or Trichloroacetic acid is applied to penetrate the out and middle layers of skin to remove damaged skin cells. The treatment is used to improve age spots, fine lines and wrinkles, freckles and moderate skin discoloration. It also can be used to smooth rough skin and treat some precancerous skin growths, i.e. actinic keratosis. Requires Physician Approval

Deep peel: Trichloroacetic acid or phenol is applied to deeply penetrate the middle layer of skin to remove damaged skin cells. The treatment removes moderate lines, age spots, freckles and shallow scars. Patients will see a dramatic improvement in skin appearance. The procedure is used on the face and only can be performed once. Requires Physician Approval

Am I a good candidate to receive a chemical peel?

You may NOT receive this treatment if you have any of the following conditions:

•Are pregnant or breastfeeding

•Are allergic to Salicylates (i.e. aspirin) or any ingredient in this peel

•Have open wounds, sunburn, infected, irritated or extremely sensitive skin

•Have active cold sores, warts, or herpes simplex

•Have used Accutane within 180 days

•Had a peel within the past 30 days

•Have used products containing Retinoic acids, AHA & BHA in the last 7 days. Doing so may cause a strong reaction

•The skin has not recovered from a recent cosmetic procedure or treatment including but not limited to waxing, Botox, Cosmetic filler, microdermabrasion, Laser, IP, Photo Facial, etc.

•Have Recent history of chemotherapy or radiation therapy

•Have dermatitis and inflammatory rosacea

•Darker skin tones may be required to purchase and use a melanin suppressant for 2 weeks prior to receiving treatment in order to reduce any undesired effects.

•Have an important meeting, event, vacation, public appearance, personal or work travel scheduled within 30 days of your treatment in which you fully understand your skin may not be completely healed.

I agree that I DO NOT have any of the conditions listed above?

Treatment Expectations:

•I acknowledge that no guarantee has been made or implied as to the results of the peels procedure.

•It is common and expected that your skin will be possibly red, itchy, dry, irritated, and discolored for several days or more.

•It is common and expected that the peel will not penetrate evenly across your skin, and the deeper “hot spots” may develop scabbing, crusting, or blisters that may last for several or more days until that skin can heal.

•It is common and expected to have some degree of peeling/flaking of the skin for several or more days. We can not predict the amount of peeling/flaking or how long it will last. Lack of visible peeling is NOT an indication that the peel is unsuccessful, you are still receiving the benefits of the peel. There are a number of reasons, including but not limited to using Retinoic Acid on a regular basis, severe sun damage or thick skin may need several peels to achieve desired results.

•Although rare, some patients may experience tiny pinpoint acne breakouts (purging), crusting, tightness, dryness, rash, swelling or a burning sensation, or minimal peeling. Post Inflammatory Hyperpigmentation (dark spots) or Hypopigmentation (light spots) may appear and last several days to weeks, or not correct at all.

•Call our office immediately if you have any serious unexpected problem after the procedure.

I fully understand and agree to the Treatment Expectations described above.

Post Care:

•I understand that it is critical to strictly follow and use the post care products and instructions provided to me to reduce/avoid any potential complications .

•I understand that it is critical not to pick at the skin, avoid intentional sun exposure and use any type of manual or chemical exfoliants in order to speed up the healing process. Doing so may cause permanent pigmentation and scarring.

•I understand that I must wear a minimum of SPF 40 Broad-Spectrum Mineral Sunscreen on the treated area immediately following my treatment for a minimum of 30 days.

•I understand that the actual degree of skin improvement cannot be guaranteed. Although most people see some degree of improvement, some may have minimal to no improvement. The peeling result varies and depends on each patient's skin condition. 2-3 treatments may be necessary to obtain desired results (depending on the severity of the skin condition) and post-care products must be used in order to achieve optimal results

•I understand that this peel contains strong acids including Glycolic, Lactic, TCA, Phenol, Salicylic Acid and Retinoic Acid. I waive any rights, present or future, to request the information of exact composition or concentration.

.•Call our office immediately if you have any serious unexpected problem after the procedure.

I fully understand and agree to the Post Care Instructions

I also agree to hold harmless and fully discharge and release forever and all time the officers, directors, employees, staff members, agents, contractors, successors and assign of Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC from any costs, expenses, or other liability whatsoever, including but not limited to attorneys' fees, compensatory, punitive, exemplary, consequential and special damages of any kind whatsoever, resulting from the service I have voluntarily chosen to undergo and any condition or result, known or unknown, that may arise as a result of such procedure or any other treatment I receive. I understand that I must inform the Esthetician or Technician performing my service of any changes to my skin and health prior to receiving any additional services/treatments in the future. As of May 4, 2024, I am of lawful age (18) and have read and fully understand the contents of this document and represent myself as physically capable of using the service offered by Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC.

​By signing this document, I agree that I have had sufficient time to read this entire document and ask any questions regarding the treatment I have elected to receive. Furthermore, my signature indicates that I have read and understand the information in the consent, and I understand all of the risks and potential complications connected to the procedure I have elected to undergo. I understand that the results of the treatment varies on an individual basis and that specific results are not guaranteed. I understand that while every precaution will be taken to prevent complications and that while complications from this procedure are rare, they can and sometimes do occur.

Cancellation Policy: Our Team of Licensed Professionals are only paid when they provide a service and only come to work when they have an appointment, so it is imperative that you provide us with at least 24 hours notice should you need to change or cancel your appointment. It is how they make a living and provide for themselves and families. Your appointment is reserving time on their calendar and it is preventing another client from doing the same. All that we ask is that you extend the courtesy to notify us in a timely manner (24 hours) should something change and you are unable to keep your appointment. If you cancel the same day or fail to show up for your appointment, your credit card that you provided to make the reservation will be charged for the entire amount of the service and you will be required to pre-pay for any future appointments, including past missed appointments. If you have an outstanding gift certificate, package credit or reward points, it will be redeemed for your missed appointment. By signing this document, you agree to and understand our cancellation policy and forfeit any right to dispute/reverse or otherwise deny a credit card transaction.

Product Sales/Gift Cards/Gift Certificates/Packages: All product sales are final and are non-refundable. In addition, Gift Certificates/Gift Cards and Packages for all services are non-refundable regardless if they were purchased online or in-store.

 









First Client's Name

First Name*

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First Client's Date of Birth*
First Client's Signature*
Second Client's Name

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

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

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

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

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

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

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

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

First Name*

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Last Name*
Tenth Client's Date of Birth*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Client Contact Information:

Cell Phone Number (no dashes): *

Referred by
Emergency Contact

Emergency Contact *

Emergency Contact Phone Number *
General Wellness
Are you currently under the care of a Physician/Dermatologist to treat a skin condition?*
No
Yes

If Yes, please explain
Are you allergic to any of the following items: (please select below)*
No
Yes
None
Aspirin
Milk
Apples
Citrus
Grapes
Latex
Fish
Iodine
Sulfur
Other:

If Yes, indicate details and date:
Skin Care Regimen - 80% of Your skin's health/appearance depends on what products you are using on your skin 365 days a year. You will never reach your skin care goals by depending on infrequent Spa Treatments and using low quality skin care at home.

What are your specific conerns/challenges with your skin? *

What skin care products are you currently using to address your skin concerns?


Cleanser:

Exfoliants/Scrubs:

Serums:

Toner:

Moisturizer:

Masks:

SPF:

Other:
Are you happy with the results from the products you are using?*
No
Yes
Skin Care Treatment History
Are you currently having skin treatments (Botox, Laser Resurfacing, Laser Hair Removal, Chemcial Peels, LED Light Treatment), etc?*
No
Yes

If Yes, indicate treatment and frequency
Are you currently using any of the below products on your skin? *
None
Benzoyl Peroxide
Glycolic Acid
Lactic Acid
Salicylic Acid
Retinol
Are you currently using any of the below topical medications on your skin? *
None
Tretinoin (Retin A, Renova, Avita)
Adepalene (Differin)
Azelaic Acid (Azelex, Finacea)
Isotretinoin (Accutane)

Please list any other topical antibiotics that may not be listed above
Are you currently experiencing or have you ever experienced any of the following conditions: *
None
Skin Cancer
Dermatitis
Keloid Scarring
Acne
Rosacea
Broken Capillaries
Hypopigmentation
Hyperpigmentation
Treatment reactions

If you checked any of the above conditions or have a condition not listed, please describe.
Waxing Services
Have you had any adverse reactions to waxing in the past (ingrown hairs, breakouts, Hyperpigmentation, Hypopigmentation, etc?*
No
Yes

If Yes, please explain:
We advise that you stay out of the sun/tanning beds 48 Hrs before & after your waxing appointment. You should begin to exfoliate the area to be waxed 1 day before your appointment and resume exfoliating 48 hours after to prevent ingrown hairs. You must exfoliate and moisturize the area to reduce/prevent ingrown hairs. 

All skin types, especially medium to dark color skin or with high levels of melanin, are prone to either hyperpigmentation or hypopigmentation (areas of discoloration or uneven color). We recommend a brightening/lightening product or treatment to reduce unwanted pigmentation, as well as the daily use of a SPF50 or higher.


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*
Parent or Guardian's Date of Birth*
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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