Chemical Peel

Chemical Peel Consent Form

 

Patient Name: ______________________

Date of Birth: ______________________

Phone Number: _____________________

Email: _____________________________

I, the undersigned, hereby consent to undergo a chemical peel for aesthetic purposes. I understand that a chemical peel involves the application of a chemical solution to my skin to exfoliate and remove damaged outer layers, improving the texture, tone, and appearance of my skin.

Treatment Explanation:

A chemical peel is a procedure in which a chemical solution is applied to the skin to exfoliate the outer layers, allowing new, healthier skin to emerge. The depth of the peel will vary, depending on the type of solution used and the desired results. Chemical peels can treat issues such as acne,

hyperpigmentation, fine lines, sun damage, etc.

Potential Risks and Complications:

While chemical peels are generally safe, there are some risks associated with the procedure, including but not limited to:

● Redness, swelling, or irritation at the treated site

● Peeling or flaking of the skin (normal process)

● Skin infection

● Pigment changes (hypopigmentation or hyperpigmentation)

● Scarring (very rare)

● Sensitivity to sunlight for a period after the treatment

● Allergic reaction to the chemicals used (very rare)

● Prolonged or abnormal skin irritation

Pre-Treatment and Post-Treatment Care:

I agree to follow the pre-treatment and post-treatment instructions provided by my practitioner. Pre-treatment instructions may include avoiding sun exposure, certain medications (such as retinoids), or active skincare ingredients before the peel. Post-treatment instructions may include

moisturizing, avoiding sun exposure, and using gentle skincare products until healing is complete.

Medical History and Disclosure:

I have disclosed all relevant medical history, including any skin conditions (e.g., eczema, rosacea), allergies, and medications I am currently taking. I understand that failure to provide full information may increase the risk of complications.

I have the following medical conditions:_______________________________________________________________________________________________________________________

Pre-Treatment and Post-Treatment Care:I agree to follow all pre-treatment and post-treatment care instructions provided by my practitioner. Pretreatmentinstructions may include avoiding sun exposure, using sunscreen, and discontinuing certain topicaltreatments (e.g., retinoids or exfoliating agents) for a period before treatment. Post-treatment care may includeavoiding sun exposure, using gentle skincare products, and applying moisturizers or healing ointments as directed.

Medical History and Disclosure:I have disclosed all relevant medical conditions, including any history of keloid scarring, active skin infections, eczema, or any other skin conditions, as well as any allergies or medications I am taking. I understand thatfailure to provide full information may increase the risk of complications.

Photographs and Media:I consent to the use of before and after photographs of the treated area for medical records, educational purposes, or marketing, with my identity kept confidential unless otherwise specified.

Acknowledgment and Consent:By signing below, I acknowledge that I have read and understood the information provided above. I consent to the

 Chemical Peal treatment and agree to follow all pre- and post-treatment care instructions. I understand thatresults may vary from patient to patient. This consent form will apply to any future chemical peel treatments with Lilo's Spa Orthotherapy & Aesthetic.

Patient Signature: ____________________________Date: ______________________Practitioner Signature: _______________________Date: ______________________Lilo’s Spa-

 

Pre-Treatment Instructions for Chemical Peel

 

Dear Client,

Thank you for choosing our Spa for your chemical peel treatment. To ensure the best possible results and minimize any potential risks, please carefully follow these pre-treatment instructions before your scheduled appointment:

1. Consultation: Ensure you have had a full consultation to discuss your treatment goals, any allergies, and medical history. It is essential to inform us if you have any skin conditions such as eczema, psoriasis, or rosacea.

2. Avoid Sun Exposure: Avoid direct sun exposure, tanning beds, or sunburns for at least 2 weeks prior to your chemical peel. Sun-damaged skin may increase the risk of pigmentation changes or complications.

3. No Waxing or Sugaring: Do not wax or use hair removal creams on the area to be treated for at least 1 week before the procedure. These methods can irritate the skin and make it more sensitive to the peel.

4. Avoid Retinoids and Exfoliants: Discontinue the use of retinoids, glycolic acid, or any exfoliating products for at least 3 days prior to your treatment. These products can make your skin more sensitive and may cause irritation during the peel.

5. Hydrate: Drink plenty of water to keep your skin well-hydrated. Proper hydration will improve the overall outcome and minimize dryness or irritation post-treatment.

6. Avoid Alcohol and Blood Thinners: Refrain from consuming alcohol for at least 24 hours before your treatment. Alcohol can increase the risk of swelling and irritation. If you are taking blood-thinning medications, please consult with us ahead of time, as these can increase the risk of bruising and irritation.

7. No Facials or Other Skin Treatments: Avoid facials, microdermabrasion, or other intensive skin treatments for at least 1 week prior to your peel. These treatments may irritate your skin and interfere with the chemical peel process.

8. Shave the Area (if necessary): If the treatment area involves facial hair, please shave the area 24-48 hours before the procedure to avoid irritation during the treatment.

9. Avoid Makeup on the Day of Treatment: Please come to your appointment with a clean face, free from makeup, moisturizers, or sunscreen, to ensure the chemical peel can be applied effectively.

10. If You Are Pregnant or Breastfeeding: If you are pregnant or breastfeeding, please inform us. Certain chemical peels may not be recommended during pregnancy or breastfeeding.

11. Post-Treatment Care: Make sure you are prepared to follow the post-treatment instructions carefully to ensure a smooth recovery and optimal results.

 

These conditions may require rescheduling the treatment.By following these instructions, you can achieve the best possible outcome for your Chemical Peel treatment.

 

Post-Treatment Care for Chemical Peel

 

Thank you for trusting us with your aesthetic treatment. To ensure the best results and minimize the risk ofcomplications, please follow these post-treatment care instructions. If you have any questions or concerns, please contact us.

1. Avoid Sun Exposure: Protect your skin from direct sunlight and avoid tanning beds for at least 2 weeks following the peel. Exposure to UV rays can cause pigmentation issues or irritation. Always apply a broad spectrum sunscreen (SPF 30 or higher).

2. Avoid Touching or Scratching the Treated Are: Do not touch, rub, or scratch the treated area. This can introduce bacteria or cause irritation to the healing skin.

3. Do Not Peel or Pick at the Skin: After the treatment, your skin may start to peel or flake. This is a normal part of the process. Do not pick at the skin, as this can cause scarring and interfere with the healing process.

4. Moisturize the Skin: Apply a gentle, hydrating moisturizer recommended by your provider to keep your skin hydrated. This will help soothe any dryness or tightness during the peeling phase.

5. Avoid Hot Showers or Steam: Avoid hot showers, saunas, or any heat treatments for 48 hours after the procedure. Heat can exacerbate irritation and cause discomfort.

6. Avoid Exfoliation and Harsh Skin Products: Do not use exfoliating products, scrubs, or retinoids for at least 7 days post-treatment. These can irritate the skin and interfere with the healing process.

7. Gentle Cleansing: Cleanse your face gently using a mild, non-irritating cleanser. Avoid rubbing or scrubbing the treated area.

8. Avoid Makeup for 24-48 Hours: It’s best to avoid makeup for the first 24-48 hours after your chemical peel to allow the skin to heal without additional irritation.

9. Hydrate: Drink plenty of water to support the healing process and maintain the hydration of your skin from within.

10. Avoid Strenuous Exercise: Refrain from vigorous exercise or activities that cause excessive sweating for at least 48 hours after your treatment. Sweating can irritate sensitive, healing skin.

11. Cold Compress for Swelling or Redness: If you experience swelling, redness, or discomfort, a cool compress can help soothe the area. Apply it for 10-15 minutes at a time during the first 24 hours.

12. Monitor for Side Effects: Mild redness, peeling, and irritation are normal after a chemical peel and should subside in a few days. If you experience severe discomfort, excessive swelling, or signs of infection (such as pus), contact our office immediately.

13. Follow-Up Appointment Your provider may schedule a follow-up session to assess your skin’s healingand discuss further treatments. Please attend all scheduled appointments.

Thank you for adhering to these post-treatment care guidelines. If you have any concerns, feel free to reachout to us.