Chemical Peel Informed Consent

Please fill out this form prior to your chemical peel appointment.

Which conditions would you like to improve?

I give permission for my skin care professional, Heather Craven to perform the chemical peel treatment.

1. I have completed the Health History form and questions above. I have been truthful about my physical conditions, pregnancy, medications that I may be taking and my current skincare regimen. I am also aware that my lifestyle which if it includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption and/or recreational use of controlled substances, will affect and diminish the effectiveness and result of the treatment.

2. I have disclosed to my skin care professional/esthetician any surgical procedures, laser treatments, or facial procedures that I have had or intend on having in the future.

3. I am not presently pregnant or lactating.

4. I have not had any recent chemotherapy or radiation treatments.

5. I have not recently waxed or used a depilatory (such as Nair) on the area being treated at this appointment. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters or cold sores.

6. I have not had any other peel treatments of any kind from another professional that have not disclosed to my skin care professional.

7. I agree to refrain from excessive sun exposure or the use of a tanning bed while I am undergoing treatment and during the 14 days following the end of the treatment.

8. I understand that sun exposure is prohibited while I am undergoing treatment and that the use of SPF is mandatory.

9. I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin. Some of the benefits include lessening of pigmentation, reduction in the appearance of fine lines and wrinkles, and control of certain conditions such as acne or occasional breakouts.

10. I understand that the following conditions preclude me from having this treatment at this time and verify that none of these conditions apply to me at this time.

11. My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, or pigmentation levels.

12. I understand the cost of treatment and the fee structure has been explained to me.

13. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complication, I will immediately contact the skin care professional who performed the treatment.

14. I understand the possibility of peeling, flaking, hyperpigmentation, and excessive dryness. I agree to use the products specifically recommended by my skin care professional/esthetician, including sunscreen.

15. I understand that every precaution will be taken to minimize or eliminate negative reactions such as blisters, redness or irritation.

16. I understand that my practitioner will recommend home care products to work in tandem with the in-clinic treatment. I am willing to follow recommendations by my skin care professional for home care.

17. I consent to the taking of photographs to monitor treatment effect and results if desired by my therapist.

Informed Consent

In the event of any questions or concerns, I will consult my skin care professional immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications and limitations. I will hold the skin care professional (Heather Craven) harmless from any liability that may result from this treatment.

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 had sufficient opportunity for discussion to have any questions answered.