Chemical Peel Consent Form

Name

First Name

Last Name

Date of Birth

YYYY

Phone

By entering your phone number, you are agreeing to receive text messages from us. You can reply STOP to opt-out.

(###)

###

####

List all Medications taken within the last 8 weeks including OTC drugs and vitamins.

Are you currently using or have you used within the past year: isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers?

Yes

If yes, please indicate what and when last used:

Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment?

Yes

List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the process of this chemical peel treatment:

Are you currently using or have you used any of the following in the past 7 days?

Check all that apply.

Alpha Hydroxy Acid (AHA)

Skin Thinning Products

Glycolic Acid

Scrubs, Peels, or Exfoliators

Tanning Beds

Retin A

Resorcinal

Do you have tendencies towards any of the following?

Check all that apply.

Ingrown Hairs

Hyperpgimentation (skin darkening)

Eczema

Breakouts

Bruising

Psoriasis

Bumps

Scarring

List allergies (if you have any).

Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin).

I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense.

I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.

I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results.

I understand that results are not guaranteed and for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/ environmental damage, pigmentation levels, or acne conditions.

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin therapist.

I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist.

Accutane Warning:

Using retinoids (accutane or similar) can cause skin to rip off during the waxing process. For your own safety, we cannot wax you until you have been off of Accutane or similar medications for over a year's time.

I understand the dangers of Accutane. Should I decide to take Accutane in the future, I will inform my aesthetician and will not get waxed or sugared at Hello Sugar LLC at any time within one year of taking the medicine.

Are you taking Accutane (or similar) or have you in the past year? *

Brand names include: Accutane, Claravis, Sotret, Accutane, Amnesteem, Myorisan.

Yes

Table Accommodations

Hello Sugar’s standard tables are of the greatest quality and accommodate up to 400 pounds. It is important to inform your aesthetician prior to your service if there is an accommodation of any kind that would need to be made for your personal safety and that of our aesthetician, if so, we will happily make adjustments to fit specific needs. Hello Sugar LLC shall not be liable or responsible for any personal injury or consequential damage of nature, whatsoever, in direct correlation to our equipment, including our treatment tables. Please note that Hello Sugar does not ever discriminate on the basis of weight. However, it is important to inform your aesthetician if there are any limitations special needs prior to your service.

I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.

The paragraph below explains the liability waiver for Hello Sugar LLC. By typing your name into the box below, you agree to hold Hello Sugar LLC harmless from all liability associated with the waxing, sugaring, and skin care.

I have completed this form to the best of my ability. I will consult with my aesthetician regarding any medicine I am currently taking and any skin tendencies that may be problematic. I give permission to my aesthetician to perform the waxing procedure, sugaring, or skin care procedure and will release and hold her, her staff, and Hello Sugar LLC harmless from any and all liability that may result from this treatment, including but not limited to disability or personal injury arising from the treatment or table accommodation. I have given an accurate account of the questions asked above including but not limited to special accommodations as well as all known allergies or prescription drugs or products I am currently ingesting or using topically, and am engaging in the treatment at my own risk. I understand medication or cosmeceuticals such as prednisone, aspirin, retin A or blood pressure medication, any and all medications used to treat acne, antibiotics that are taken either orally or topically, hormonal changes that naturally occur during your menstrual cycle, any and all products applied topically to the skin that are intended to exfoliate, compromised skin such as skin that has been exposed to the sun, dehydrated or dry, and caffeine and alcohol consumption are all items that can affect the service. I understand my aesthetician will take every precaution to minimize or eliminate negative reactions as much as possible, and as such I hereby release the aesthetician and Hello Sugar LLC from any and all liability or responsibility for any such injury or damage. Hello Sugar LLC and its owners, affiliates, subsidiaries, employees, agents, and authorized persons do not make any promises, guarantees, etc. regarding the results one may achieve following completion of the treatment.

Company

Connect

Education