Chirally Correct Peel Consent
Patients Name ____________________________________ Date _______________________
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I have completed the client medical form accurately
I have been candid in revealing any condition that could prohibit this treatment such as
cold sores, pregnancy, and use of hormones, recent facial surgery or laser resurfacing,
recent use of Retin-A or use of Accutane within the last 12 months
I understand that there is no guaranteed result from this treatment. Many variable such
as age, sun damage, on going sun exposure, smoking, excessive alcohol intake,
climate, diet and water intake, skin thickness and sensitivity can effect the outcome. I
understand that I may or may not peel and that each case is individual.
Regardless of the precautions taken, I acknowledge the possibility of an adverse
reaction to the peel and accept sole responsibility for any medical care that may become
necessary. I will immediately contact the Doctor or Nurse or Esthetician performing the
treatment of any adverse reaction
I will not scratch, pick, pull at or abrade the treated skin
I understand that direct sun exposure and use of tanning booths is prohibited during this
treatment time and that it is mandatory to use a minimum SPF 15 sun protection daily.
I understand that to achieve maximum results the recommended home care routine
must be followed. I understand that if I alter the routine or use products not
recommended by the skin care professional the results could be altered or inhibitive. I
also understand that it may take several treatments to obtain the desired results.
I understand that the following side effects or complications can occur:
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Discomfort
Redness and Swelling
Hypopigmentation
Itching ir irritation
Skin peeling or flaking up to 14 days after the procedure
Infection
Scarring
Hyperpigmentation
Acne breakouts
I understand the goals of the treatment as well as the limitations and possible
complications.
The technician has provided the information and has answered all of my questions
concerning this procedure. I clearly understand the above information.
Cost of per treatment $ ________________, or a series of _________ at $ ________________
Signed __________________________________________ Date _______________________
Esthetician ___________________________________________________________________
75 PROSPECT STREET, STE. 115, HUNTINGTON, N.Y. 11743
WWW.THESKINCLINICONLINE.COM | (631) 456-2075
Patient Instructions for Chemical Peels
Peels are most effective in a series of 6 peels pf gradually increasing strength, followed by
monthly maintenance peels. Peels can be added to your regular facials.
Prior to peel series:
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Discontinue use of Retin-A (tretoin) or other topical medication (i.e. Differen) for 24 hours
Avoid waxing, electrolysis or cream depilatories for 48 hours
Avoid shaving within 4 hours of your appointment
Following each peel:
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Do not apply skin products to the face for three hours after the peel (eye & lipstick makeup are OK)
Avoid using any products with ingredients that have retina, AHA’s or other exfoliates
Avoid waxing, electrolysis or cream depilatories for 48 hours
Avoid using any products with ingredients that have alcohol, witch hazel or other
astringents
Daily Maintenance:
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AM – Wash with a gentle cleanser, rinse with tepid water and pat dry. Apply sun block
daily (may be used as moisturizer). If needed, you can apply moisturizer before make
up is applied.
PM – Wash with a gentle cleanser, rinse with tepid water and pat dry. Apply moisturizer
as needed.
Make up may be applied daily. A water or mineral based foundation is recommended.
Note: Patients with oily skin types map experience a period of mild folliculitis (clogged hair
follicles), especially around the chin area.
75 PROSPECT STREET, STE. 115, HUNTINGTON, N.Y. 11743
WWW.THESKINCLINICONLINE.COM | (631) 456-2075