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Dermagal Esthetics & Spa

Chemical Peel Consent

Before your chemical peel treatment, please take a few minutes to review and complete this consent form. Your answers help ensure the safest, most effective treatment for your skin.

Personal Information

Let's start with the basics.

Please enter your full name.

Pre-Treatment Agreement

Please read each item carefully, then initial below.

  • Superficial chemical peels are topical exfoliants applied to the skin to soften the dead skin layer and exfoliate the skin. This helps restore the skin to a more youthful, smooth, and beautiful appearance. Possible side effects include and are not limited to: brown or white spots, scabbing, peeling, scarring, uneven skin color, redness, and rough texture.
  • Do not use prescriptive or over-the-counter topical, abrasive scrubs, or stronger exfoliants 3 to 5 days pre-treatment and 7 days post-treatment.
  • No prolonged sun exposure 2 weeks prior or post treatments.
  • Sun protection of at least SPF 30 will be worn daily with frequent re-applications if outdoors.
  • I am currently not taking or using any medications that are contraindicated to receiving a chemical peel.
Please enter your initials to continue.

Current Medications

List any medications, topicals, or supplements you are currently using. If none, leave blank.

If you are using Retin-A, Accutane, or any prescription exfoliants, please let your esthetician know before treatment begins.

Post-Treatment Understanding

Please read and initial each statement.

I understand that, following treatment, my skin may appear red and feel like it has a mild sunburn. I understand that anytime the skin barrier is compromised there is a small risk of infection. I will contact my esthetician immediately should this happen. I agree to care for my skin post-treatment in the manner suggested by the esthetician.

Please enter your initials to continue.

I UNDERSTAND THAT I AM NOT TO PICK THE FLAKING SKIN AS THIS COULD CAUSE UNWANTED PIGMENTATION, SCARRING, OR PERMANENT DAMAGE.

The chemical peel treatment has been fully explained and my questions or concerns have been addressed. I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin, pore size, wrinkles, or the percentage of improvement expected following treatment due to each individual's unique reactions.

I understand that no specific results are guaranteed.

Signature

By signing below, I acknowledge that I have read the above information and thereby consent and agree to the treatment with its associated risks.

I hereby consent to receive a chemical peel.

Please sign above to continue.
✓

Thank you, there!

Your Chemical Peel Consent Form has been submitted.
Please hand the iPad back to your esthetician.

Treatment Tracking

Treatment Log

Treatment tracking stays on this device and is not submitted.