Skin Peel Consent Form

Client Name: *

Date: *

Date of Birth: *

Email: *

Address: *

Postcode: *

Home Phone:

Mobile: *

May we contact you by text and/or email?

Text Email

Do you consent to us taking before & after photographs? *

Yes No

Do you consent to us using these for promotional purposes? *

Yes No

This form is to give you informed choice regarding peels.

What are the Side effects and Risks?

Please tick the boxes you have read, understood and discussed as required with your clinician.

1. Redness is usually minimal and short lived 2. Swelling is usually very minimal and short-lived 3. Peeling is usually superficial - mild and short in duration 4. Scarring is very unusual but may occur 5. Hyper pigmentation (dark areas of skin) or texture changes may occur and although very rare may temporarily or possibly permanently occur 6. Moles/blood vessels/freckles and sunspots may become more obvious and darker after the procedure since layers of dead cells are removed 7. Milia (white heads) may appear but will usually disappear quickly 8. Eye injury although very rare if chemicals get into the eye - scarring and visual disturbances may occur 9. In extremely rare cases a significant allergic reaction can occur. This could include redness/facial swelling and soreness lasting several days. If these symptoms occur please contact us for advice.

Please tick the boxes you have read, understood and discussed as required with your clinician.

• I am aware that if I suffer from facial herpes a peel may trigger an attack. • Although acid peeling can lighten pigmented skin - I acknowledge that there is no guarantee that dark discolouration (melasma) will be reduced - faded or permanently erased.

Consent

I have been thoroughly counselled in a language that I understand on the procedure for Skin peels. I have been informed about the possible risks. I am therefore willing to proceed.

Patient: *

Tap or click on the signature above to sign

Skin Peels - Aftercare Advice

A chemical peel is a rejuvenation treatment to refine and improve the condition of facial skin. It is done by treating damaged outer layers with a chemical solution that causes a process leading to shedding off dead skin cells and superficial layers, and stimulating new cell growth. The peel you have received is balanced to create the best peel results with as low as possible an incidence of any potential side effects.

It is vital that you protect you skin from the damage that UVA and UVB rays cause by using a sufficient UVA / UVB sunblock. Your practitioner will have recommended after care products designed to work in harmony with the peels you are having and it is very important to follow the skin care routine that has been discussed.

Please do not touch or rub the treated areas. You may gently apply mineral make-up post treatment, or apply your normal makeup once any redness has calmed.

Avoid extreme changes of temperature until all redness has settled completely.

The side effects created are rare and mild in nature, and are normally a direct result of the effect of the peel, such as itching caused by the regeneration of new skin cells taking place. You can control your itching in a variety of ways, but the main thing to remember is scratching may bring temporary relief, but it also may result in wasted time, money, and suffering if you do not heal correctly because of scratching. A cold compress will soothe the skin, and in extreme cases an antihistamine from your pharmacy may help.

If you experience any of these or other symptoms, please contact us at your earliest opportunity for advice and support.

If you have any concerns please contact your practitioner.

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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