Chemical Peel – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details:

Are you currently taking any medications or supplements (oral or topical)?

Yes

No

Are you currently using Retin-A, Accutane, or any topical acne treatments?

Yes

No

If yes, please let us know:

Are you pregnant or trying to conceive?

Yes

No

Are you currently breastfeeding?

Yes

No

Have you had any recent cosmetic procedures (laser, fillers, peels, microneedling)?

Yes

No

Please describe and include dates : *

Skin Concerns & Goals

What are your skincare objectives?

Which products are you currently using?

Treatment Information & Contraindications

Have you had a chemical peel before? *

Yes

No

If so, when did it happen and what was your experience?

Have you experienced any allergic reactions to skincare products in the past ?

Yes

No

Do you currently have any cuts, open wounds, or active skin infections in the area to be treated

Yes

No

Have you had recent sun exposure or tanning (natural or artificial)?

Yes

No

Risks, Side Effects, and Acknowledgements

Please read and initial each statemen regarding Chemical Peel Facial:

I understand that chemical peels are designed to exfoliate the skin and promote new cell growth.

I acknowledge that temporary side effects may include redness, flaking, stinging, tightness, and increased sensitivity.

I understand that the intensity of the peel and downtime varies based on the type of peel and my skin's condition.

I understand that results may vary and multiple treatments may be required for optimal results.

I agree to avoid sun exposure, active products, makeup, and exercise for the time period advised by my practitioner.

I will notify the clinic of any side effects or concerns that occur following treatment.

I understand that chemical peels are not suitable for all skin types or conditions and that my skin may react differently.

Client Declaration and Consent

I confirm the information provided is accurate and complete to the best of my knowledge.

I have had the opportunity to ask questions and all were answered to my satisfaction.

I understand the nature of the chemical peel treatment, its risks, benefits, and alternatives.

I voluntarily consent to receive chemical peel treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Deposit & Risk Acknowledgment Policy

Non-Refundable Deposit

I understand and agree that any deposit made for medical consultations, procedures, or treatments is non-refundable under all circumstances. This applies regardless of cancellation, rescheduling, or change of decision on my part.

Assumption of Risk

I acknowledge that all medical treatments, procedures, or interventions carry inherent risks. I have been informed of the potential benefits, risks, and alternatives related to my care, and I have had the opportunity to ask questions. I voluntarily assume full responsibility for any and all risks, outcomes, or complications that may arise from the medical care I receive. I release the provider and facility from liability for outcomes that are not guaranteed and may vary from patient to patient

Confirmation of Understanding

By signing below, I confirm that:

- I have read and fully understood this policy

- I understand the deposit is non-refundable.

- I accept and assume all risks related to my treatment.

- I sign this document voluntarily and without coercion.

Patient Name

Patient Signature:

Clear

Date: *

I agree to terms & conditions provided by the company.

Privacy Policy | Imprint