Chemical Peel/ Green Peel Consent Form
Chemical Peel/ Green Peel Consent Form Royal Faces 101 Amber Harris License#: 126512 A chemical peel can be used to diminish the appearance of fine lines and wrinkles, improve texture/tone, reduce pore size, increase hydration and moisture retention, give skin a smoother appearance and diminish the appearance of hyperpigmentation and or acne scars. Layers of product are applied based on your unique skin composition and needs. Multiple treatments are required in order to obtain optimal results spaced 4-6 weeks apart. Due to variables such as age, condition of your skin, sun damage, smoking, skin care products, climate, life-style, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results. Contraindications: 1. Pregnancy/Lactating 2. Herpes Simplex (cold sores or fever blisters). An anti-viral medication may be necessary prior to treatment. 3. Extensive sun or tanning 3 days prior and 3 days post treatment. 4. Accutane in the past 6 months to 1 year. 5. Topical retinol products in the past 2 weeks. 6. Waxing of area to be treated in the past 7 days. 7. Any other chemical peel within 14 days of the treatment. 8. Skin must be healthy and intact. 9. An allergy to aspirin. This signature represents that you are aware of the contraindications of the peel that you are receiving and none of the above applies to you. Date: __________________________ Signature: ____________________________________ I am aware of the following risks/complications that may occur: 1. Mild to moderate discomfort or pain 2. Slight redness or swelling 3. Sun sensitivity 4. Skin sensitivity 5. Pigment changes 6. Scarring 7. Allergic reaction 8. Bacterial infection I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorize Amber Harris, licensed esthetician to perform one or more chemical/ green herbal peels on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Amber Harris/Royal Faces101 from all liabilities associated with this procedure. This consent is valid for all of my chemical peel treatments in the future as well. Signature____________________________________________ Date____________________________