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Chemical Peel Treatment Consent Form

Please read carefully and complete all sections

Patient Information

Skin Assessment

Fitzpatrick Skin Type (circle one):

Type I
Always burns, never tans
Type II
Usually burns, tans minimally
Type III
Sometimes burns, tans uniformly
Type IV
Rarely burns, tans easily
Type V
Very rarely burns, tans very easily
Type VI
Never burns, deeply pigmented

Peel Type (to be completed by practitioner)

Superficial Peel (e.g., Glycolic, Lactic, Mandelic) - Minimal downtime
Medium Peel (e.g., TCA 15-35%, Jessner's) - 5-7 days recovery
Deep Peel (e.g., Phenol, High TCA) - Extended recovery, medical supervision required

Contraindications - Please confirm you do NOT have any of the following:

Pregnancy or breastfeeding
Active cold sores, warts, or skin infections in treatment area
Use of isotretinoin (Roaccutane) within the last 6-12 months
Active eczema, psoriasis, or rosacea in treatment area
History of keloid or hypertrophic scarring
Recent facial surgery, laser treatment, or dermabrasion (within 6 months)
Allergy to aspirin or salicylates (for salicylic peels)
Currently using retinoids, AHAs, or other exfoliating products (must stop 5-7 days prior)

Risks and Potential Complications

I understand that the following may occur:

Expected: Redness, tightness, peeling/flaking (varies by peel depth)
Common: Temporary increase in sun sensitivity (SPF 30+ required)
Uncommon: Post-inflammatory hyperpigmentation (higher risk in darker skin types)
Uncommon: Hypopigmentation (lightening of skin)
Rare: Scarring
Rare: Infection requiring treatment
Rare: Allergic reaction or contact dermatitis
Rare: Reactivation of herpes simplex (cold sores) - antiviral prophylaxis may be recommended

Patient Acknowledgements

By signing below, I confirm that:

I have stopped using retinoids/exfoliating products as instructed
I will avoid sun exposure and use SPF 30+ for at least 4 weeks post-treatment
I understand multiple treatments may be needed for optimal results
I will NOT pick, scratch, or peel flaking skin
I have disclosed all medications including topical treatments
I understand the risks as explained above
I have received aftercare instructions
I am over 18 years of age
Data Protection Notice (GDPR): Your personal and medical information will be stored securely in accordance with UK GDPR and the Data Protection Act 2018.

I have read and understood this consent form and agree to proceed with treatment.

Patient Signature
Date
Practitioner Signature
Practitioner Name (Print)

This consent form template is provided by Aestheticc for informational purposes only.

Please have your legal/insurance advisor review before use. Updated January 2025.