Chemical Peel Consent Form – Celebrity Skin Studio

Date*

Name*

First Last

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Current Age*

If you are a minor, in addition to this form, you must fill out a General Intake & Waxing consent form, including the parental consent portion. This form is located on the website under the FORMS tab.

What to expect from a Chemical Peel

The treatment you will receive is designed to exfoliate or remove the outer layers of the skin. Your participation in you skin care treatments will determin e the outcome. It is important that you strictly adhere to your home care products that your esthetician has recommended. No guarantee is expressed or implied as to the precise results, peeling times or discomfort. During the treatment you may experience some temporary stinging or warm flushing. This will fade within a few minutes. During the next few hours you may eperience some tightening of the skin, which may last for serveral days. For most clients flaking or peeling begins within 48 hours. It is impossible to pre-determine how much peeling will occur. The shedding process usually subsides within 5-7 days. Depending on the type of peel performed and your skin quality the following reactions may occur in some clients: 1.) Prolonged redness, irritation & flakiness 2.) Dryness and sensitivity 3.) Severe allergic reactions in some instances. It is also important to note that there are different types and strengths of chemical peels. Not every person is going to shed skin and have the same reaction. This does not mean the treatment is not working. Because of the nature of this treatment it is essential that PRE and POST instructions be followed.

Check the skin care concerns you would like to improve*

Check all that apply

Fine Lines/Wrinkles
Pigmentation/Dark Spots
Acne Scars
Reduction of Redness
Reduction of Oil or Acne
None of the Above

Have you had a chemical peel before*

Yes
No

If yes, when and what type of peel was it?

What is your current skin care routine?*

What are you currently using on your skin, include any professional or drug store products you use.

Which Skin Conditions best describes your skin?*

Check all that apply

Oily
Acne
Dry/Dehyrated
Rosacea/Redness
Normal

Smoking History*

Check all that apply

I do not smoke and have never been a smoker
Previous smoker
Live with a smoker
I currently smoke

Allergies*

LIst any allergies you may have, include medications, seasonal, environmental etc. If none list N/A

Have you been treated for any of the following?*

Please check all that apply

Cancer
Acne
Skin Disease
Diabetes
Depression
Blood Pressure
None of the above

If you checked any boxes above please provide information

List when and what type of treatment you received

List any other medical conditions here if none list N/A*

List any Medications if none list N/A*

Remember to list birth control if applicable

Are you pregnant or nursing?*

Yes
No

Are you prone to cold sores?*

Yes
No

If yes, you will need to consult your doctor to see if they recommend having you start a course of antiviral medication prior to your appointment.

Are you allergic to aspirin?*

Yes
No

Have you used any glycolic products in that last 24 hours?*

Yes
No

Have you used any retinols in the last 72 hours?*

Yes
No

Have you taken Accutane in the last year?*

Yes
No

Are you currently under the care of a Dermatologist or using any prescription products for your skin?*

Yes
No

If yes, you will need to consult with your Dr. prior to scheduling an appointment and provide details below.

If you answered yes to the above questions please indicate what your are being treated for and what medications you are using.

Are you currently using hydrocortisone?*

Yes
No

Have you had radiation treatments?*

Yes
No

If yes, you will need to consult with your doctor about getting skin care treatments.

Hormone Treatments*

Are you doing fertility treatments? Trying to get pregnant or having any Hormone Therapy (for Pregnancy or Menopause) please list details. If none of the above list N/A

Have you had any recent Skin Care or Cosmetic procedures?

List any medical or cosmetic procedures such as injections, resurfacing treatments/laser or chemical peels, surgeries etc. that have been received within the last year. It is important to keep your technician updated on any procedures received.

I understand a post peel kit will need to be purchased for aftercare.*