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Peel Consent Form

     To the CLIENT: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

1. I voluntarily request that the staff at Laser Luxury perform the Peel procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin.

2. Peels, despite their high levels of efficacy and safety, are not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.

3. It is important to use sun screen of SPF 25 or greater when exposed to the sun.

4. I understand complications can include white heads, cold sores, infection, scarring, numbness and permanent discoloration, particularly in people with dark skin.

5. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time. Clinical results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.

6. Post care should include sun exposer for at least 5 days, or longer if the skin is still irritated. Use cold water to wash your skin. Aloe or after sun lotions may be applied to easy any discomfort.  Avoid saunas and steam rooms.  Do not use any scrubs, acids, AHAs, retinol or tretinoin on your skin.  Use a medium to heavy moisturizer and/or a barrier repair cream. 

7. I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand and agree that all services rendered to me are charged to me directly and that I am personally responsible for payment. The nature and purpose of the treatment have been explained to me.

8.  I understand and agree to the 24 hour $25 cancellation policy.  If I miss or need to cancel/reschedule the appointment with in 24 hours I will pay the fee and give consent for my card on file to be charged. 

I Agree

I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment

I Agree

May 30, 2025

First Client Name
First Name*
Last Name*
Phone*
First Client Date of Birth*
Date of Birth
First Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
First Client Signature*
Second Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Second Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Third Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Third Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Fourth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Fourth Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Fifth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Fifth Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Sixth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Sixth Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Seventh Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Seventh Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Eighth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Eighth Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Ninth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Ninth Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Tenth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Tenth Client Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
No
Yes
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Client 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(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*
Date of Birth
Parent or Guardian's Information
Do you have any skin allergies, or sensitivities?
List current medications
Recent sun exposure?*
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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