Chemical Peel Consent Form

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

A chemical peel can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance of hyper pigmentation. Layers of product are applied based on your unique skin composition and needs. Multiple treatments are required in order to obtain optimal results spaced 2-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results.

Contraindications:
• Pregnancy/Lactating
• Herpes Simplex (cold sores or fever blisters). An anti-viral medication may be necessary prior to treatment.
• Extensive sun or tanning 3 days prior and 3 days post treatment.
• Acutance in the past 6 months to 1 year.
• Topical retinol products in the past 2 weeks.
• Waxing of area to be treated in the past 7 days.
• Any other chemical peel within 14 days of the treatment.
• Skin must be healthy and intact.
• An allergy to aspirin.

I am aware of the following risks/complications that may occur:
• Mild to moderate discomfort or pain
• Slight redness or swelling
• Sun sensitivity
• Skin sensitivity
• Pigment changes
• Scarring
• Allergic reaction
• Bacterial infection

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure. I consent and authorize , RN, BSN to perform one or more chemical peels on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release from all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the future as well.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :