Chemical Peel Consent Form

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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 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.

 

 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.

 

 I understand that I am not to pick the flaking skin as this could cause unwanted pigmentation, scarring, undesired, 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.

 

 I have read, understand and I consent to the terms of this agreement. By signing below, I assume any risk, harm or injury which may occur as a result from the chemical peel services and I give my permission to my esthetician at SOS WAX and Skincare to perform the services. I will hold the esthetician and SOS WAX and Skincare harmless of any liability and waive any claims that may result from the services.


Signee Information

If so, please list all (including over the counter drugs / herbal supplements)

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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.