I, _______________________________, have read the below information and initialed each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my skin therapist.

I give permission to my therapist, ________________________, to perform the chemical treatment we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I understand she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate account of any over the counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to my esthetician. I am not ingesting or using topically any other over the counter product or prescription medication/agent that has not been disclosed to my therapist. I am not presently pregnant or lactating and I am over the age of eighteen (18). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

____________I understand that I should not have a chemical peel if I intend to continue to have excessive sun exposure.  It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.

 

____________I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my therapist.

 

____________My expectations are realistic and I understand that the results are not guaranteed and that for maximum (Client Initials)  results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne condition.

 

____________I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but  agree to inform the skin professional immediately if I have concerns or am overly uncomfortable during treatment or after I return home.

 

____________I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions.  I agree to use a moisturizer specifically recommended by my esthetician and I acknowledge that I have been informed of the possible negative reactions (intense erythema, welts, scabs) and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my therapist immediately.

 

Client Name (printed) ____________________________________________________________________________

Client Name (signature) _ _____________________________________________ Date________________________

Esthetician_________________________________________________________Date________________________