Chemical Treatent Form

PCA Skin® chemical peels
Healthy Skin Clinic
15 Madison St.
Huntington N.Y. 11743
(631) 683-4200;
Patient profile
Name: __________________________________________ ___
DOB: ____________ Age: ______ Sex: ______
Address: ____________________________________________ City: ____________________________________
State: ______ Zip: ___________
Home Ph: _____________________ Cell Ph: __________________________
E-mail Adress:
 Are you pregnant or lactating?
Yes ___ No ___ (If so, only the Oxygenating Trio or Detox Gel is appropriate)
 Do you wear contact lenses?
Yes ___ No ___ ( remove contacts if eyes are sensitive)
 Do you have permanent make-up? Yes ___ No ___ ( if so, to what areas of the face?) ________________________
 Do you currently have a sunburn/windburn/red face?
Yes___ No___ Why? ___________________________
 Are you in the habit of going to tanning booths? Yes___ No___ (if within past three weeks, decline treatment!)
 Do you currently use or receive depilatories or waxing? Yes___ No___ (Discontinue use 7 days pre and post treatm.)
 Are you applying any topical medications at this time? Yes___ No___ Which one(s)?________________________
(High percentages of certain ingredients may increase sensitivity)
 Are you currently using any topical Retinoid prescriptions (Retin-A®/Renova®/Differin®/Tazorac®/Avage®?)
Yes___ No___ What strength? _______________ For how long? ___________ (Discontinue use 5-10 days
before and after treatment)
NOTE: consult your physician before discontinuing use of any prescription.
 Are you currently using Accutane®? Yes___ No___ How long?_____________
It’s OK to apply ONE layer of
Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®.
Those who are currently taking Accutane® should be directed to their dispensing physician.
 Have you had a chemical peel or any type of procedure with a medical device? Yes___ No___ (peels should follow
injections by 2-5 days to prevent movement of the filler).
 Have you recently had facial surgery?
Yes___ No___ Describe:_______________ How long ago?__________
 Have you recently had laser resurfacing? Yes___ No___ When?_____________ What kind?_________________
 What type of work do you do?__________________ Regular airline travel? Yes___ No___ How often?__________
 Do you participate in vigorous aerobic activity or sports? Yes___ No___ What type?_________________________
 Do you smoke or use tobacco? Yes___ No___
 Do you develop cold sores/fever blisters? Yes___ No___ Last breakout?__________________________________
 Are you allergic/sensitive to: (check all that apply) milk___ apples___ citrus___ grapes___ aloe vera___
aspirin___ perfumes___ lates___ hydroquinone___ mushrooms___ If any other allergies, what?____________
 Are you sensitive to alcohol-based products?
Yes___ No___
 Have you ever used any other products that caused a bad reaction? Yes___ No___ Describe:_________________
 Are you taking any medication at this time? (antibiotics may increase sensitivity) _____________________________
 What is your hereditary background?________________________________________________________________
Natural eye color: Blue___ Green___ Hazel___ Gray___ Lt.Brown___ Med.Brown___ Dk.Brown___
Natural hair color: Blonde__ Red__ Lt.Brown__ Med.Brown__ Dk.Brown__ Black__ Gray/Silver__ White__
Skin tone: Pale/White__ Light__ Medium__ Reddish__ Freckled__ Lt.Olive__ Med.Olive__ Dk.Olive__
Lt.Brown__ Med.Brown__ Dk.Brown__ Soft Black__ Black__ Sallow__
 Do you consider your skin:
Sensitive___ Resilient___ Not sure?___
 Describe your skin (check all that apply): Thick__ Thin__ Saggy__ Firm__ Normal__ Dry__
T/Zone/Combination__ Oily__ Acne__ Comedones/Blackheads__ Milia__ Cysts__ Breakouts__ Acnescarred__ Large pores__ Small pores__ Florid__ Rosacea__ Eczema__ Freckled__ Sun-damaged__
Uneven/blotchy__ Mature__ Wrinkled__ Patchy dryness on__ Sallow__ Melasma__ Perfume-stained__
Hypopigmentation__ Psoriasis__ Hyperpigmentation__ Dehydrated (lacking moisture)__ Asphyxiated__
Telangiectasia/broken surfacecapillaries__
 What is your daily care regimen? ___________________________________________________________________
 What are the cosmetic improvements you would like to see in your skin? ____________________________________
Consent form
Continued treatment
Prior to receiving treatment, I have been candid in revealing any condition that may
Have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to
treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, use of
Retin-A®, Accutane®, Differin®, Tazorac® or Avage®.
I understand there may be some degree of discomfort; i.e.: stinging, pin-prickling
sensation, heat, or tightness.
I understand there are no guarantees as to the results of this treatment, due to many
variables, such as: age, condition of skin, sun damage, smoking, climate, etc. I understand I
may or may not actually peel, that each case is individual.
I understand this treatment is a cosmetic treatment and that no medical claims are
expressed or implied.
I understand that to achieve maximum results, I may need several treatments.
I understand that although complications are very rare, sometimes they may occur and
that prompt treatment is necessary. In the event of any complications, I will immediately
contact the doctor/clinician who performed the treatment.
I agree to refrain from tanning in tanning booths while I am undergoing treatment, and
during the 14 days following the end of treatment.
I understand that extended direct sun exposure is prohibited while I am undergoing
treatment, and the daily use of sunscreen protection with a minimum of SPF 15 is
I have not had any other chemical peel of any kind within 14 days of the treatment. I
understand I cannot have another treatment within 14 days of this treatment, whether it is
performed at this location or any other location.
I hereby agree to all of the above and agree to have this treatment be
performed on me. I further agree to follow all post-peel care instructions as I
am directed.
Signature: _______________________________________________
Initials: _________
Signature of Clinician: _____________________________________
Signature of Witness: ______________________________________
Date: _________________________