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Chemical Peel Consent Form

In the field of skincare, we define the process of removing excess accumulations of dead cells from the skin as peeling or exfoliation. This can be done by using products (Glycolic acid etc.) formulated to achieve specific results known as chemical peels. The process involves an application to the skin in an area with a cotton swab or small brush. The chemical is left on the skin for a certain period of time depending on the solution, product strength, skin type, skin condition, sensitivity, age, or prior use of any exfoliating agent to obtain a specific result. The rate of improvement depends on age, skin type, condition, degree of the sun or environmental damage, pigmentation levels, as well level of peel being used. To achieve maximum results it is recommended to do a series of treatments.

Potential Benefits

I acknowledge that no guarantee has been made about the results of the procedure. Some areas of improvement that may be achieved are as follows:

Softer smoother skin
Reduction in the appearance of lines and wrinkles
Reduction in acne lesions
Reduction in the appearance of sun or age spots

Potential Risk

Although it is not possible to list every potential risk and complication, I agree I have been informed of some possible risks and complications which may include but are not limited to the following:

Swelling and redness
Scabbing or peeling of treated skin and surrounding areas
Prolonged skin sensitivity
Areas of increased or decreased pigmentation
Burning of the skin

Any potential risk and complications could result in the need to discontinue the treatment.

I agree to keep my skincare specialist informed of any change in medication or products during treatment.

I agree to keep my skincare specialist informed on any concerns or discomfort during treatment.

I certify that I am over the age of eighteen (18), that I am not pregnant or nursing, on Accutane, or taking any other medication that might affect the procedure.

I have read and will follow to the best of my ability any and all instructions.

I understand the potential risk of complication and choose to proceed after considering the possibility of both known and unknown risks, complications, and limitations.

By signing below I authorize DuVall's School of Cosmetology to perform the following peel.

Glycolic Lactic Salicylic Enzyme

While some peels are neutralized and removed during treatment, I understand that TCA and Jester's peels are applied in layers and are not fully removed.

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July 30, 2021 12:12 am CDT

Chemical Peel Consent Form Uploaded by DuVall Adminitrative Staff - haleigh@haleighlenz.com IP 47.24.68.104

September 30, 2021 10:27 pm CDT

DuVall Front Desk - front_desk@duvallschool.com added by DuVall Adminitrative Staff - haleigh@haleighlenz.com as a CC'd Recipient Ip: 47.24.68.104

September 30, 2021 10:27 pm CDT

DuVall Appointments - appointments@duvallschool.com added by DuVall Adminitrative Staff - haleigh@haleighlenz.com as a CC'd Recipient Ip: 47.24.68.104

September 30, 2021 10:27 pm CDT

DuVall Education - education@duvallschool.com added by DuVall Adminitrative Staff - haleigh@haleighlenz.com as a CC'd Recipient Ip: 47.24.68.104