Chemical Peel Consent Form

I hereby give my consent for the treatment of chemical peel to be done to my face and/or areas of my body.

The procedure, benefits, and risks of Chemical Peel was explained to me. I understand and acknowledge the risks and benefits.

I understand that this treatment is a program. It may require sessions or cycles in order to reach my desired results. It has been explained to me that this treatment is an outpatient procedure that can be done in clinics or offices.

It has been explained to me that during treatment, I might feel a burning sensation that would last for 1-2 minutes upon application of the chemical to my skin. I understand that after a few days, the area where the chemical peel was applied may darken and/or shall become glossy or shiny. These days might prevent me from visiting work or go to places where I will be exposed to sunlight. In this regard, I shall comply with the strict requirements given to me by the doctor.

I understand that there are no guarantees that the desired result would be achieved.

I understand that complications may occur, although this is rare. In case such happens, it must be treated immediately by my doctor. Complications may appear as:

Allergic reactions due to medications or with the chemical peel or both;
Keloids or thick scars;
Increased or decreased pigmentation;
Sensitivity to the wind or sun;

Use of photographs for educational and publishing materials

I consent to have my photographs taken before, during, and after my treatment. I understand that using these materials will not fully reveal my identity. The purpose of this is for education and possible marketing.I do not consent to have my photographs taken before, during, and after my treatment.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Signature

Date