CHEMICAL PEEL CONSULTATION

AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Medical History

Consent and Acknowledgment

Pre Chemical Peel Contra-indications that indicate the peel should NOT be performed

I Consent I currently DO NOT HAVE:

  • Inflamed acne cyst Recent Retin-A use.

  • Active herpes

  • Recent depilation (48 hours) Roacutane use

  • Irritated or damaged skin

  • Open cuts in the area Sunburned skin

  • Severe physical or mental stress

  • Allergy to Medik8 homecare productsI

  • Understand that there is no refund for any of the services performed

  • I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.

I CONSENT AND ACKNOWLEDGE

  • I have been informed about the aftercare instructions and commit to following them diligently.

  • I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.

  • I understand the costs associated with this procedure and accept full responsibility for these costs.

  • I certify that I have voluntarily sought the services provided and consent to the treatment.

Clear