ChemPeel


Lavender-Falls-Stone-Oak-Spa-San-Antonio

Lavender Falls Face & Body Spa LLC

Client Informed Consent Form

Chemical Peel

 

PLEASE READ CAREFULLY & COMPLETELY

 

19239 Stone Oak Pkwy #201

San Antonio, Texas 78258

Phone: 210-446-0903

www.sanantonio.lavenderskinspa.com

Online Booking Available

Treatment Consists of:

A chemical peel is a skin-resurfacing procedure in which a chemical solution is applied to the skin to remove the top layers. The skin that grows back after a chemical peel is smoother and younger looking. Chemical peels are used to treat wrinkles, skin discoloration and scars.

Clients Acknowledgements:

Clients with active cold sores or warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated. Inform the esthetician.. You should also not have a chemical peel treatment if you have a history of allergies, rashes, or other skin reactions, or may be sensitive to any of the components of this treatment. Most peels should not be performed on patients with an allergy to salicylates (i.e., aspirin). This peel is also not recommended if you have taken Accutane within the past year, or received chemotherapy or radiation therapy and should not be administered to pregnant or breastfeeding (lactating) women.

Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

      Accutane with the last year

      Allergies

I am not allergic to any of the ingredients in the prescribed chemical peel treatment.

      Sunburn or Sun Exposure- 1 week prior to treatment.

      Recent Laser Treatments or Chemical Peels

      Electrolysis, Waxing , Depilatory Creams , Laser Hair Removal – 1 week prior to treatment

      No prescriptive topicals, abrasive scrubs or strong exfoliants – 1 week prior to and post treatment.

(Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol, glycolic acid, salicylic acid)

      Any products containing AHA or BHA, or benzyl peroxide or Any exfoliating products that may be drying or irritating – 3 days prior to treatment.

      Pregnant or Breastfeeding

      Chemotherapy or radiation therapy

Cosmetic Injections:

      Botox/Dysport/Xeomin within the last week.

      Dermal Fillers within the last two weeks.

Post Treatment Acknowledgement

      No prescriptive topicals, abrasive scrubs or strong exfoliants- 1 week prior to and post treatment.

(Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol, glycolic acid, salicylic acid)

       No prolonged sun exposure 2 weeks post treatment.

      Sun protection of at least broad spectrum SPF 30 must be worn whenever outdoors and re-applied frequently.

      Your skin may be more red than usual for 2-3 days. Please avoid strenuous exercise during this time.

       Approximately 48 hours after the treatment, your skin will start to peel. This peeling will generally last 2 to 5 days. DO NOT PICK OR PULL THE SKIN.

      When washing your face, do not scrub. Use a gentle cleanser.

      Apply a light moisturizer as often as needed to relieve dryness and tightness.

      Do not have any other facial treatments for a least one week after your peel.

      You may resume the regular use of Retin-A, alpha-hydroxy acid (AHA), or bleaching creams only after the peeling process is complete.

Side Effects:

Possible side effects include but are not limited to: slight or extreme redness, swelling, stinging, itching, tenderness, and dry or flaking skin. I UNDERSTAND THAT I AM NOT TO PICK OR PULL THE FLAKING SKIN AS THIS COULD CAUSE UNWANTED PIGMENTATION OR SCARRING. Most side effects will gradually diminish over time as healing may take several days or longer. Call the office immediately if you have any unexpected problems after the procedure.

Acknowledgements:

      I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

      The chemical peel treatment has been fully explained and any questions or concerns that I have, have been addressed.

      I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

      I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

      Photographs May be taken for comparison for future treatments for my chart.

 

I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.

 

I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.

 

All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.

 

Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face & Body Spa LLC for your aesthetic needs

Feel free to contact us at 210-446-0903 if you have any questions

 

       

Leave this empty:

Signature arrow


Signature Certificate
Document name: ChemPeel
lock iconUnique Document ID: 54edc115fbe993d334333e61aaca9c2880893ab8
Timestamp Audit
April 8, 2017 8:01 pm CSTChemPeel Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP 162.198.97.65