• LEVEL III PEEL CONSENT

    Please read through all pages of this form thoroughly at least 7 days prior to your peel treatment.
  • PEEL INFORMATION

  • ABOUT THIS PEEL

    Our Level III peels are medium-depth chemical peels. These peels typically are a stronger blend of chemical exfoliants at slightly higher percentages than our Level I & II. Our blends contain: Trichloracetic Acid (TCA)/Ferulic Acid/Tazarotene, TCA/Phenol, Mandelic Acid/Glutathione/Phytic Acid/TCA, Resorcinol/Salicylic Acid/Kojic Acid and Retinol/Arbutin/Lactic Acid/Salicylic Acid/Kojic Acid/Phytic Acid. Level III peels may also have a longer application time with some of these peels needing to remain on the skin for at least 45 minutes during initial treatment.
     
    HOW LONG DO THE RESULTS OF THE PEEL LAST?

    The effects of Level III peels are long-lasting when you are using the correct homecare products. Overall peeling and downtime with these peels are minimal. You can expect to have active peeling for 7-10 days. This type of peeling would be more consistent with what you most often see associated with chemical peels. You may need to remain indoors for the first 3 days of the peel and you probably will not be able to wear makeup during your peeling process.

  • PEEL INSTRUCTIONS

    Please read thoroughly. Feel free to print this page out if you need to.
  • CLIENT PRE PEEL CARE INSTRUCTIONS

    • Discontinue use of Retin-A, Renova, Adapalene, Hydroxyl Acid, Differin Gel, Glycolic Acid, Salicylic Acid, or Retinol/Vitamin A derivative product for at least one week prior to your peel.

    • If you are being treated for pigmentation, your skincare provider will provide a pigment inhibitor to be used twice a day 30 days prior to treatment.

    • Avoid tanning and extreme sun exposure for at least 30 days prior to your peel.

    • You will not be treated if you have an infection or severe cold/flu OR are taking an antibiotic.

    • You cannot have the peel treatment if you have used Accutane or its derivatives within the last year.

    • You cannot have the peel if you are pregnant, breastfeeding, have active cancer or are currently undergoing chemotherapy or radiation.

    • You cannot have the peel treatment if you have active herpes. If an antiviral medication has been prescribed for you, you must begin taking the first dose Two (2) days prior to your appointment.

    • Please ensure that you have adequate sun protection in the form of a hat and scarf to be utilized directly after treatment.

    • Do not wear contact lenses to your appointment. 

    WHAT TO EXPECT DURING PEEL - INSTRUCTIONS

    The First Day

    Immediately following your peel treatment, you are not to wash your face or get the area wet for at least 6 hours. You can enhance your results by leaving it on the skin for a full 24 hours.

    You will want to avoid working out, saunas, steam rooms, swimming pools, an excessively hot baths/showers for the duration of your peel.

    The Second Day

    You can wash your face with a gentle cleanser and apply moisturizer and SPF. It is imperative to reapply your SPF every two hours if you are being exposed to the sun (whether that be through outside or sitting near windows). You will not use any active serums for the next 7-10 days. Inbetween cleansings, you may apply Aquaphor to the skin when you start feeling dry and tight. You will gently pat this into the skin. 

    If your skin may begin to feel itchy, you can apply a hydrocortisone cream.

    The Third to the Tenth Day

    By the third day, you will have active skin peeling. This typically will start around the mouth and move upward and outward until the entire face is peeling. DO NOT PEEL OR PULL OFF THE SKIN as this could relate in scarring and permanent damage.

    You will continue to follow the use of the gentle cleanser, [serum, if approved], moisturizer and SPF. Keep applying the Aquaphor by patting gently so as not to rub the skin off prematurely. 

    By the tenth day, you should be done peeling or only have some remnants of dead skin around your hairline. To remove these final bits of peeling, it is recommended to use an enzyme mask for 10 minutes.

     

    Be Advised

    During the peel you may go out, but you MUST protect yourself from exposure to the sun. Wear a large hat out of doors, sunglasses and a silk or light cotton scarf to protect your neck. Take particular caution whilst driving in a car. The sun is intensified through glass, so protect the sides of your face as well as your neck, with a scarf. Limit time spend outside to the cooler part of the day. During the winter, protect your face from the cold and wind with a light woolen scarf across your cheeks.

     

    Important Notes

    • Drink lots of fluids, especially the first two days. Try to drink 8 to 10 glasses a day. (preferably water and fruit juice)

    • Avoid alcohol during this period.

    • Oral antihistamine such as Benadryl may help with itching, but is sedating so do not drive whilst taking antihistamines.

    • Try to rest as much as you can.

    • From the moment your face begins to peel, DO NOT expose your new skin to the sun, wind and cold.

    • If it is absolutely necessary to expose your skin to these elements, be sure to protect the new skin with a sun screen cream obtainable from us.

    • Do not exercise profusely. Perspiration could irritate the skin. Avoid excess heat, steam or extreme cold.

     

  • Acknowledgement

    By signing below, you acknowledge that you have read and agree to the information provided.
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  • POST-PEEL INSTRUCTIONS

    Please read for how to handle your skin in the days immediately following your peel-off.
  • POST-PEEL INSTRUCTIONS

    Your post-peel regimen will be explained to you in detail by your esthetician.

    • You should use a very mild, non irritating cleanser recommended to you by your esthetician. Cleanse your skin using only your finger tips in gentle circular motions. The use of a facial brush, sponge or cloth should be avoided. Rinse skin using lukewarm water. Hot or very cold water should be avoided. Do not rub, pick or scratch at your skin. Gently blot skin dry using a soft clean piece of paper towel or microfiber soft towel and apply your appropriate salon recommended creams.

    • Avoid the use of toners, scrubs and antiseptic soaps for 2 weeks post peel off. Products containing skin irritants such as Retinol, Benzoyl Peroxide, Glycolic/Salicylic acids, Astringents or Vitamin C should be avoided for a period of two (2) weeks post peel off or until all sensitivity has resolved.

    • Moisturize your skin adequately. Your esthetician will recommend gentle, fragrant free, mild soothing post peel skin care products until all skin sensitivity has resolved.

    • Avoid sun exposure for at least three (3) months post peeling. The skin is vulnerable and sun damage can easily occur.

    • Ensure that you use adequate sun protection at all times including on cloudy days. Sunscreen must be used vigilantly to help prevent pigmentation issues that may be caused by direct and indirect sunlight. The sun is intensified through glass, so precaution whilst driving in your car should be taken by protecting your skin with a scarf. Sunscreen along with a hat, sunglasses, scarf and even an umbrella should be used whenever outdoors. Darker skinned individuals should be extra diligent about sun protection.

    • Makeup may be used.

    • Do not wax, tweeze or use a depilatory product on your face or neck for at least 2 weeks post peel.

    • Do not use a self tanner.

    • Avoid exercise that causes excessive perspiration as well as saunas and steam rooms for two (2) weeks post peeling as this could irritate the skin.

    • Once skin sensitivity has resolved, your esthetician will suggest an appropriate skin care regimen. Continue using gentler products should you experience any sensitivity.

     

    PLEASE NOTE: We cannot be held responsible if after care instructions are not carefully adhered to.

  • Acknowledgement

    By signing below, you acknowledge that you have read and agree to the information provided.
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  • MODEL RELEASE

    This custom peel does require photographs and your consent to use said photographs.
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  • I hereby consent to having clinical photographs taken before, during and after my peeling procedure. I understand that these photographs are an important part of my medical record.

    I consent to and authorize the use and reproduction by FAIRY GLOW MOTHER® of any and all photographs which you have taken of me, for any purpose whatsoever, without further compensation to me. All negatives and positives, together with the prints, shall constitute your property, solely and completely. 

    By signing, I certify that I am 18 or more years of age.  

    I, the undersigned Model, assign to you the right to copyright photography.

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  • ANTIVIRAL MEDICATION RELEASE

    Please choose whichever statement below applies to you and sign and date before submitting.
  • Instructions for Anti-herpes medication if you are undergoing the Skin Renewal Peeling
    treatment. If you have ever had a fever blister or cold sore at any time in the past, you will be required to take an Antiviral Medication to prevent an outbreak from occurring.

    Please request one (1) of these four medications from your doctor’s office:
    ZOVIRAX
    FAMCICLOVIR A
    CYCLOVIR
    VALTREX

    You will need 5000mg for each peeling treatment. Please request 10000mg in total for
    your two peels.

    You will take 1000mg of the medication for five (5) consecutive days. You begin by taking the pills two (2) days before your peeling treatment. You will continue to take your medication on the two (2) days of the peeling application and then on the day following your second application. This will constitute taking the Anti-Viral for 5 consecutive days.


    Do not miss a dose.

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  • CONFIDENTIAL SKIN & MEDICAL HISTORY

    Please read through each question thoroughly and answer truthfully to the best of your knowledge.
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  • ACKNOWLEDGEMENT

    I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications from the treatment. I am aware that it is my responsibility to inform the skin care therapist of my current medical or health conditions and to update this history.
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