Chemical Peel Consent Form

I understand, accept and am in agreement with the following:

I have disclosed all known allergies(Required)
I have not had cosmetic injectables or other cosmetic procedures in the last 2 weeks(Required)
I have not had other resurfacing treatments (chemical, physical or laser) in the last 7 days.(Required)
I have informed my clinician of all additional skin devices I have at home (microcurrent, needle/rolling, LED etc)(Required)
I do not have metal plates, implants, or a pacemaker.(Required)
I am not pregnant, breastfeeding or actively trying to conceive(Required)
I am not using prescription skin medication, either topical or oral (e.g. Roaccutane, Oratane).(Required)
I understand that redness, flaking, peeling and sensitivity are potential outcomes of my treatment and I will get in contact with my clinician should I be concerned.(Required)
I understand that the afore mentioned downtime is necessary to achieve the best result.(Required)
My clinician has verbalised post-care instructions and I have received a hard copy which I agree to comply with(Required)
I understand that individual results will vary, and the outcomes are dependent on my lifestyle factors (e.g. sun exposure, smoking, diet, alcohol consumption) as well as my adherence of the program outlined by my clinician.(Required)
I have taken the necessary precautions/antivirals to prevent a herpes simplex/cold-sore breakout from my treatment (if applicable).(Required)
Although every precaution is taken, I have been made aware by my clinician that unlikely side effects can occur such as redness, swelling, hyperpigmentation, hypopigmentation, irritation, skin peeling, skin flaking, acne breakouts, scarring, rashes and infection up to 2 weeks post treatment. I understand that these side effects cannot be predicted, and it is therefore imperative that I follow the post-care instructions provided to minimise the risk.(Required)
I consent to before and after photographs being taken of my skin to monitor the progression of my treatment. (When exemplary results are achieved you may be asked if they can be used for media and marketing purposes. Photographs cannot be shared without a signed release form which is additional to this).
Client Name(Required)
DD slash MM slash YYYY