Treatment Readiness

Consent

CHEMICAL PEEL CONSENT FORM

Glo With Ally

CHEMICAL PEEL CONSENT FORM

A chemical peel is a cosmetic procedure that involves the application of a chemical solution to the skin, which helps to exfoliate and improve its texture, reduce the appearance of wrinkles, fine lines, acne scars, hyperpigmentation, and uneven skin tone. The treatment may cause temporary redness, stinging, peeling, and increased sensitivity.

I have been fully informed about the chemical peel treatment, including its purpose, benefits, and potential risks. I understand that the treatment is elective and that there are alternative treatments available. I acknowledge that no guarantees or warranties have been made regarding the results of the treatment.

I understand that the chemical peel involves the use of chemicals that may cause a mild to moderate tingling or burning sensation during the application. There may be temporary redness, swelling, peeling, crusting, or discoloration of the skin. In rare cases, there may be pigmentation changes, scarring, or infection. I agree to inform the esthetician immediately if I experience any unusual or adverse reactions during or after the treatment.

Is this your first time recieving this specific service at Glo With Ally

Yes

Have there been any changes to your health history, medications, skincare routine, allergies, pregnancy status, or any other information that may affect your treatment since you last completed your consultation form.

Yes

If you answered 'Yes,' please complete a new consultation form for this service to ensure your information is current and accurate.

Please check the circle to confirm your understanding

I understand the importance of following the post-treatment instructions provided by the esthetician, which may include avoiding sun exposure, excessive heat, picking or scratching the treated area, and following a recommended skincare routine.

Mutiple Sessions Acknowledgement

I acknowledge that multiple sessions may be required to achieve desired results and that the frequency and strength of future treatments will be determined based on my skin's response and individual goals.

Liability Release

I release the esthetician and the salon from any liability regarding any complications, issues, or dissatisfaction that may arise from the chemical peel treatment.

Accuracy Declaration

I certify that the information I have provided is complete and accurate to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the safety and effectiveness of my treatment. I agree to notify Glo with Ally of any changes to my health, medications, skincare products, or other relevant information before receiving future services.

Type Full Name to Sign

Date of Signature

I agree to the terms outlined above.

Yes

By checking the validation box and typing your name, you acknowledge that you have completely read and fully understand the above agreement, and that your typed name stands as your legally binding digital signature under the US ESIGN Act.