Date * Name *
* Phone * Email *
Date of Birth *
MM slash DD slash YYYY
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
Have you had a chemical peel before * 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
Smoking History *
Check all that apply
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
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? * Are you prone to cold sores? *
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? * Have you used any glycolic products in that last 24 hours? * Have you used any retinols in the last 72 hours? * Have you taken Accutane in the last year? * Are you currently under the care of a Dermatologist or using any prescription products for your skin? *
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? * Have you had radiation treatments? *
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. * I agree to avoid direct sun exposure for 2 weeks after the peel. * I agree to use SPF daily. SPF 30 or greater is recommended. * I agree not to wax 7 days before or after my chemical peel. * I agree not to use Retin-A (retinol products) 5 days before or after my peel. * I agree not to pick, peel scratch the skin during the healing phase. * I agree to follow up with scheduled appointments recommended by my esthetician. * PRE & POST Treatment instructions BEFORE Your Treatment:
If possible arrive with no make up and cleansed skin. It is important to discontinue hydrocortisone cream prior to your treatment. You must discontinue any products with Glycolic Acid at least 24 hours before your appointment. You must discontinue Retinol products of any kind at least 5 days prior to your appointment. You should not have any waxing services done on the treatment area within 7 days before treatment. Be sure to disclose any medications you are taking (oral or topical). AFTER your chemcial peel:
Use room tempature water to cleanse your skin. Avoid casuing perspiration and things that cause interernal and or external heat/flushing, For example avoid using hair dryer around the area or eating or drinking things that might make u flush or hot like spicy foods. Do not wax the area for 7 days after. Do not use Retinol products for 5 days after. Use only your post peel kit, and do not use any other products unless directed by your esthetician. Wear sunscreen daily. Avoid direct sun exposure for 2 weeks after your peel. It is very important that you do not pick, peel, scratch or otherwise try to remove skin during the healing phase, this also includes scrubbing or rubbing or other means of exfoliating. I understand and agree to follow the PRE and POST Peel instructions listed above. Consent for Treatment and Liablity Waiver *
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 treatments/procedures 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 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, 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 agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.
Signature * Date *
MM slash DD slash YYYY