Chemical Peel Intake Form

A chemical peel can help make your skin look better by reducing fine lines, wrinkles, and pore size, improving texture, and giving your skin a smoother appearance. It also aims to increase hydration, reduce hyperpigmentation, and enhance moisture retention. The process involves applying layers of products based on your skin's unique needs. To achieve the best results, multiple treatments are recommended, spaced 2-6 weeks apart. However, it's important to understand that factors like age, skin condition, sun damage, lifestyle, and general health can influence the outcomes. Due to these variables, there are no guarantees or warranties that you will be satisfied with the results.

Contraindications:

• Herpes Simplex (cold sores or fever blisters). An anti-viral medication may be necessary prior to treatment.

• Extensive sun or tanning 3 days prior and post treatment.

• Accutane in the past 6 months to 1 year.

• Waxing the area to be treated in the past 7 days.

• Any other chemical peel within 14 days of the treatment.

• Topical retinol products in the past 2 weeks.

• Skin must be healthy and intact.

• An allergy to aspirin.

I am aware of the following risks/complications that may occur:

• Mild to moderate discomfort or pain

• Slight redness or swelling

• Sun sensitivity

• Skin sensitivity

• Pigment changes

• Allergic reaction

• Bacterial infection

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