Informed Client Consent: Chemical Peels
Name:______________________________________________________________________________
Address:_________________________
_________City:_________________State_____Zip:__________
Phone: ___________________________ Email Address:______________________________________
Are you currently using any prescription or over-the-counter medications? Yes No
If yes, please list: _____________________________________________________________________
Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or
tranquilizers? Yes No
If yes, please indicate what and when last used: _______________________________________________
Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing
condition that may interfere with the outcome of this treatment? Yes No
List any allergies you have: ________________________________________________________________
List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or
compromise the process of this chemical peel treatment:
______________________________________________________________________________________
Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical
peels within the past year? Yes No
Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin? Yes No
Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? Yes No
Are you currently pregnant or breastfeeding? Yes No
Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical
peel treatment, please be aware of the following information and possible risks and indicate that you fully understand
what to expect. Please initial:
____ I understand that there are risks and complications associated with having a chemical peel and that, very rarely,
permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate
negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema,
blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness,
irritation, redness, and/or peeling of the skin).
____ I understand that this chemical procedure is expected to make the skin feel uncomfortable while
being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly
uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns
regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist
immediately. I understand that if I choose to consult a physician, that I do so at my own expense.
Continued a
Associated Skin Care Professionals
member
