Informed Client Consent - Chemical Peels

Informed Client Consent: Chemical Peels

Name

Address

Street Address Line 2

CityState

Zip

Phone

Email Address

example@example.com

Are you currently using any prescription or over-the-counter medications? Yes/No

If yes, please list:

Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers? Yes/No

If yes, please indicate what and when last used:

Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment? Yes/No

If yes, please describe:

List any Allergies you have:

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:

Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year? Yes/No

If yes, please describe:

Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin? Yes/No

If yes, please describe:

Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated? Yes/No

Are you currently pregnant or breastfeeding? Yes/No

Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial the following statements:

I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin). Initials:

I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense. Initials:

I understand that I should not have a chemical treatment 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. Initials:

I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that 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, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results. Initials:

I understand that results are not guaranteed and for maximum 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 conditions. Initials:

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin therapist. Initials:

I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist. Initials:

I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. 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. I do not hold the skin therapist, whose name appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.

Client Name (Printed)

Client Name (Signature)

Clear

Date

Skin Therapist/Licensed Aesthetician:

Rachel Trudeau

Owner, Blue Sun Esthetics