Consent and Release Form for Chemical Peel

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Today's Date:

Sun May 18 2025 08:29

Please read and answer

Purpose of Procedure:*

The purpose of this procedure is to improve the appearance of the skin by applying a chemical solution that causes the outer layer to exfoliate and eventually peel off. The new, regenerated skin is typically smoother and less wrinkled.

Description of Procedure:*

The chemical peel procedure involves the following steps:

Cleansing the skin.
Applying the chemical solution (such as alpha/ betta or lactic hydroxy acid, trichloroacetic acid, or phenol) to the skin.
Allowing the solution to remain on the skin for a specified time.
Neutralizing the solution and removing it from the skin.
Applying post-treatment care products.

Aftercare Instructions:*

I understand that following the procedure, I will be given specific aftercare instructions, which may include:

Avoiding sun exposure and using sunscreen
Applying prescribed or recommended ointments and moisturizers
Avoiding picking or peeling the skin
Following a gentle skincare routine
Monitoring the treated area for signs of infection or other complications

Risks and Complications*

I understand that while chemical peels are generally safe, there are potential risks and complications, including but not limited to:

Redness and irritation
Changes in skin color (hyperpigmentation or hypopigmentation)
Scarring
Infection
Allergic reactions
Prolonged healing process

Contraindications*

I understand that I should not undergo a chemical peel if I have any of the following conditions:

Active skin infections or open wounds in the treatment area
Active cold sores or herpes simplex
Severe rosacea or eczema
History of keloids or hypertrophic scarring
Recent use of isotretinoin (Accutane) within the last 6 months
Recent facial surgery or procedures
Sunburn
Pregnancy or breastfeeding
Known allergies to any of the chemicals used in the peel
Autoimmune disorders affecting the skin

Acknowledgment of Understanding:*

I acknowledge that:

I have had the opportunity to ask questions about the procedure, its risks, and benefits.
All my questions have been answered to my satisfaction.
I understand that no guarantees or promises can be made regarding the results of the procedure.

Consent to Procedure:*

By signing this form, I voluntarily consent to the chemical peel procedure performed by the practitioner listed above. I understand that I can withdraw my consent at any time prior to the procedure.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

Legal Name:*

Chosen name:

Address:

Postcode:

Date of birth:*

If you are under 16 your parent/guardian will be required

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #: