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Chemical Peel Consultation and Consent Form

Covid-19 Screening

To ensure the safety of all parties and to stop the further spread of the Covid-19 virus, please complete the below questions as honestly and accurately as possible prior to your appointment date.

Medical Information

This is an informed consent document which has been prepared to assist your Skincare Specialist to inform you about skin peel and skin treatment procedure(s), the risks, and alternative treatment options.

It is very important that you read this information carefully and completely.

Contraindications

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for skin peel treatment and must be disclosed and discussed with the specialist prior to treatment.

Please check all that apply and give details below:

PRE TREATMENT INSTRUCTIONS

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- Do not apply Retin-A, Renova, Tazorac, and/or Differin 2 weeks prior to, and for 2 weeks after your peel, to the treatment area. - Do not sun tan or use the tanning bed 4 weeks prior to, and for 4 weeks after your treatment. - Stop any type of depilatory treatments (waxing, depilatory creams) to the area of treatment, 2 weeks prior to, and for 2 weeks after your peel. - Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of treatment, 4 weeks before and for 4 weeks after your peel.

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POST TREATMENT INSTRUCTIONS

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- When cleansing, do not scrub. Use a gentle cleanser as directed by your Skincare Specialist. - With any peel, your skin may start to peel 1-3 days after the peel and continue to peel for up to 5 more days; however, it is also possible your skin may not peel at all. - Do not peel, pick or scratch the treated area, as this may result in scarring. - Apply polysporin, bacitracin or Vaseline to dry flaky areas or as directed by your Skincare Specialist. - Do not have any other facial treatments for at least 2 weeks after your peel or until the skin is smooth and back to normal. - If given a cortisone cream by your Skincare Specialist, please apply it 1-3 times per day to red irritated areas or as directed. Follow any additional and all instructions given to you by your Skincare Specialist. - Always wear your sunscreen; apply a sunscreen with SPF 30 every morning.

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Consent

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An acid solution is used to peel away the skin’s damaged outer layers. The new cells and collagen are stimulated during the healing process to produce a smoother, tighter, younger-looking skin surface. A peel does not eliminate sagging or excess skin. Each treatment is customized for patient skin type, specific problem areas and the delicate areas of the face. The depth of the peel is dependent on the concentration and type of acid, the duration of contact, and a person’s skin type and sensitivity.

Appointment Guidance

  • If you have answered yes to any of the above questions we will be in contact as you may need to reschedule your appointment with us.

  • Please only attend at your appointment time.

  • Please ensure you are on time - if you are late this may result in your appointment being cancelled.

  • Please attend your appointment unaccompanied.

  • Please limit the personal possessions you bring with you.

  • Please wear a face mask/covering to your appointment.

  • Upon arrival please wait until you are called forward to reception.

  • Upon arrival please use the hand sanitiser provided.

  • Please maintain social distancing where possible.

  • If you experience Covid-19 symptoms after your appointment please contact us immediately.

Please read the following information carefully and tick the appropriate boxes to show your understanding and acceptance:

Thanks for submitting!

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