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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

April 28, 2025

First Client Name

First Name*

Last Name*

Phone*
First Client 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*
Second Client 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*
Third Client 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*
Fourth Client 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*
Fifth Client 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*
Sixth Client 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*
Seventh Client 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*
Eighth Client 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*
Ninth Client 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*
Tenth Client 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*
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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