Chemical Treatment Consent Form

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Please complete this treatment consent form and return a minimum of 24 hours before your scheduled chemical peel exfoliation treatment.

Your Name and Today's Date *

I understand that there are no guaranteed results from this chemical peel. Many variables may affect the outcome; including, but not limited to: age, UV damage and exposure, smoking, alcohol intake, diet, climate, medical history, diet and water intake. *

I understand and agree with the statement above.

I have been completely forthcoming in revealing any conditions that might prevent this treatment; including, Hormone Replacement Therapies, Birth Control, Pregnancy, Herpes Simplex, recent cosmetic procedures, laser resurfacing, the use of retinol within 3 days prior to peel, and any autoimmune diseases. *

Yes and I understand and I am in compliance

I will not pick, microderm, peel, or scratch any treated skin. *

I agree and I will comply

I accept sole responsibility for any possibility of an adverse reaction and any medical care that it may require. *

Yes, I do accept sole responsibility

I will not expose my skin to direct UV exposure from natural or unnatural sources for a minimum of one month, preferably long-term compliance with a physical block while refraining from peak sun exposure hours. I have been advised that sun exposure increases the probability of age damage elastosis and hyperpigmentation and even more so after a chemical peel. *

I will comply with these directives for a minimum of one month after this peel.

I will comply with these protective directives as long as I am having chemical exfoliation.

I understand that to receive the best results I will need to comply with a home care regime of no acidic products for a minimum of one week. This includes AHA or BHA acids that might be in cleansers, serums, etc. I understand that if I do not comply with this, I could "over process" my own skin at home. *

I will comply with the non-acidic post peel skin treatment regime for one week

I understand that there are possible side effects that can occur post-peel. They are: redness, discomfort, hyperpigmentation, itching, irritation, acne breakouts, infection, hypopigmentation, and edema. I will contact my esthetician to up date them on my post-peel healing, if I have concern. *

I understand the possible side effects of chemical peels as stated above

Have you received or self-performed a low pH peel in the last 2 months? If so, you are ineligible for a peel at this time. *

No, I have not received or done a low pH peel on myself in the last 2 months

To prepare for your peel, it is strongly encouraged that you discontinue use of Retinol for 3 days prior to your service. *

Yes, I have discontinued Retinol use for 3 days prior to my scheduled chemical peel

The esthetician has provided information and I am satisfied with no further questions concerning this procedure. I understand that the esthetician is advising me within the scope of her practice as licensed by the state of SC and is not licensed as a medical professional. *

I understand and have no further questions

By typing your name into this box you are accepting the Chemical Treatment Consent Form and agreeing to the precepts within this form. *

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