Advanced Chemical Peel Consent and Waiver Form

Consent and Waiver Form

Skin Conditions (select one or more)

Superficial wrinkles, fine lines Acne / acne-prone / rosacea Hyperpigmentation (sun or brown spots)

The treatment you will receive is designed to exfoliate or remove dead skin cells on the outer (epidermal) layers of the skin. Depending on the treatment, you may experience some temporary burning, itching, stinging or warm flushing. This will fade within 5–10 minutes but you should tell your professional skin therapist about these sensations. During the next few hours, you may experience some tightening of the skin, which may last for several days. For some clients, a light flaking may begin within 2–3 days after treatment. It is impossible to pre-determine how much peeling will occur. The shedding process usually subsides within 7–10 days. Should a small scab or blister develop do not tamper with the spot as scarring and additional pigmentation can occur as a result of manipulation by the client, such as picking.

Your full participation during and after the treatment will determine the outcome. It is important that you strictly adhere to the homecare products and regimen that your professional skin therapist has recommended. It is possible to have a poor reaction or less-than-expected improvement of the skin. No guarantee is made or implied as to the precise results, peeling times or discomfort.

Please initial those that apply:

I have not received a cosmetic or resurfacing skin procedure such as laser, light therapy, chemical peel or microdermabrasion within the past 2 weeks.

I am not pregnant or lactating.

I am not allergic to Aspirin.

I have not used any prescribed topical medications such as Benzoyl Peroxide, Antibiotics, or Retin-A.

I do not have any active cold sores.

I have not used Isotretinoin (also known as Accutane) in the past 6 months.

I agree to apply sunscreen protection (minimum SPF30) daily.

I agree to notify my professional skin therapist of concerns.

I agree to follow the prescribed protocol.

I agree to avoid direct sun for 2 weeks.

I agree to not wax for 72 hours.

I release and indemnify Dermalogica and Image Skincare and Saving Faces LLC, their affiliates and subsidiaries, and their respective officers, directors, agents and employees, of and from any liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the advanced Peel treatment, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Dermalogica and/or Image Skincare and Saving Faces LLC.

Client (print name)

Signature

Date

Witness (print name)

Signature

Date

I have received a copy of the Post-Treatment Instructions for Advanced Peel.

"(Required)" indicates required fields

Skin conditions (select one or more)

Superficial wrinkles, fine lines

Acne / acne-prone / rosacea

Hyperpigmentation (sun or brown spots)

Please initial those that apply.

I have not received a cosmetic or resurfacing skin procedure such as laser, light therapy, chemical peel or microdermabrasion within the past 2 weeks.(Required)

I am not pregnant or lactating.(Required)

I am not allergic to Aspirin.(Required)

I have not used any prescribed topical medications such as Benzoyl Peroxide, Antibiotics, or Retin-A.(Required)

I do not have any active cold sores.(Required)

I have not used Isotretinoin (also known as Accutane) in the past 6 months.(Required)

I agree to apply sunscreen protection (minimum SPF30) daily.(Required)

I agree to notify my professional skin therapist of concerns.(Required)

I agree to follow the prescribed protocol.(Required)

I agree to avoid direct sun for 2 weeks.(Required)

I agree to not wax for 72 hours.(Required)

Client (print name)(Required)

Client signature(Required)

Date(Required)

I have received a copy of the Post-Treatment Instructions for Advanced Peel.(Required)

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Text to Book:

Advanced Chemical Peel Consent and Waiver Form

Consent and Waiver Form

Treat yourself

I'm looking forward to working with you!