Skin Blends Client Consent Form For Epidermal Peels

By Paul Smith,2014-05-12 23:06
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Skin Blends Client Consent Form For Epidermal Peels

    Skin Blends Client Consent Form For

    Epidermal Peels

    (20% Salicylic Acid, 30% Glycolic Acid, or 30% Lactic Acid)

Our superficial peels usually result in little to no downtime. Our professional strength acids are performed as part of

    a corrective treatment designed to give the skin the maximum exfoliation with minimum irritation. Client’s skin

    should be “pre-treated” by using 5% (sensitive) - 10% lactic acid nightly for 2 weeks prior to the peel, stopping 72

    hours pre and post treatment.

What can I expect to feel during the acid application?

    A stinging or burning sensation is felt by most individuals, however, depending on your skin’s own sensitivity level,

    you may experience very little to no sensation at all. You do not have to experience a “sensation” to obtain results.

What can I expect in the days following my treatment?

    Side effects vary among individuals. Some clients will have no visible side effects; peels can lighten, tighten, and

    brighten skin even if the client does not experience any peeling. Others clients may experience tightness, mild

    flaking and temporary dryness, mild redness, small blisters and mild scabbing. You are not to pick skin if it begins

    to flake or peel as this could cause trauma to the skin, resulting in hyperpigmentation.

What difference can I expect to see in my skin?

    Although no guarantee is made as to the outcome, most people feel the skin is much smoother after the first

    treatment. With subsequent treatments, in combination with the recommended homecare, it is not uncommon to see

    dark spots fade, fine lines become minimized, fewer blackheads, oil production seems lighter and breakouts fewer.

    Usually, a series of peels are recommended, followed by monthly maintenance peels.

Because there are potential side effects, my signature below indicates that I have read the above, and that I

    understand and certify that each of the following statements are true:

    1. I am not currently pregnant, or lactating.

    2. I am not currently, nor have I used Retin-A on my face, neck or chest in the past 6 weeks.

    3. I am not currently, nor have I taken Accutane, Prednisone, Differin, or any type of steroid in the past 6


    4. I am allergic to:___________________________________________________________

    5. I have discussed any hormonal changes or supplements with my skin care professional.

    6. I am not currently, nor have I used Benzoyl Peroxide in the past 2 weeks.

    7. I have not waxed area to be treated in the past 48 hours, nor will I within 14 days of this treatment.

    8. I have not shaved area to be treated in the past 8 hours.

    9. I have not used a tanning booth or laid out in the sun in the past week, and I agree to refrain from tanning

    booths and sun bathing for 21 days following this treatment.

    10. I have not had a chemical peel or dermabrasion procedure in the past 90 days.

    11. I have not had, nor will I have any other kind of exfoliation treatment within 14 days of this treatment.

    12. I have not had facial surgery within the past 6 months (okay only with doctor’s approval).

    13. I do not currently have a burn, rash, cut or puncture on my face, neck or chest.

    14. I am not prone to Herpes Simplex (cold sores/fever blisters), or if I am, I am currently taking preventative


    15. I understand that this is a cosmetic procedure and no medical claims are expressed or implied and that no

    outcome is guaranteed.

    16. After the treatment, I will not use any abrasive substances on my skin (such as loofahs, Buf Pufs, pumice

    stones, scrubs, etc.)

    17. Prior to and after the treatment, I will not use any harsh substances or exfoliating products on my skin for a

    period of 72 hours. This includes rubbing alcohol, acetone, any alpha or beta hydoxy acid product, Retin-A,

    benzoyl peroxide, etc.

    18. After the treatment, I will not expose my skin to direct sunlight for a period of 72 hours. I also understand

    that I must always use a sunscreen with a minimum of SPF 30.

    19. After the treatment, I will not apply makeup (except mineral make up) until the next day.

    20. After the treatment, I will immediately contact the skin care professional who performed this treatment if I

    have any concerns about the state of my skin.

    I understand all of the above, including the contraindications, and hereby give my consent for an

    epidermal peeling procedure.

Printed Name:__________________________________________________________________


City:____________________________________ State___________ Zip___________________

Home Phone:______________Work Phone:_________________ Cell Phone:_______________

Signature:______________________________________ Date:_________________________

Skin Care Professional:____________________________ Date: _________________________

    Client should be provided with a copy of this consent form.

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