Mariana's Esthetics
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Client Consent—Chemical Peels

I, _______________________________, have read the below information and initialed each section to indicate that I 

fully understand what to expect. If I have any questions or concerns, I will address these with my skin therapist. I give 

permission to my skin therapist, ________________________, to perform the chemical treatment we have discussed 

and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I understand my 

skin therapist will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other 

reactions, as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate 

account of any over-the-counter or prescription medications that I use regularly, and I am not presently using (nor have 

I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical 

procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not 

disclosed to my skin therapist. I am not ingesting or using topically any other over-the-counter product or prescription 

medication/agent that has not been disclosed to my skin therapist. I am not presently pregnant or lactating and I am 

over the age of eighteen (18). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn 

or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a 

history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition 

that may interfere with the positive outcome of this treatment. ____________

client initials

I understand that I should not have a chemical peel if I intend to continue to have excessive sun exposure. It has 

been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will 

require regular use of sunscreen. ____________

client initials

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my therapist.


client initials

My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, 

more than one application may be required. The rate of improvement of my skin depends on my age, skin type and 

condition, degree of sun/environmental damage, pigmentation levels, or acne condition. ____________

client initials

I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree to 

inform the skin professional immediately if I have concerns or am overly uncomfortable during treatment or after I 

return home. ____________

client initials

I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for following 

home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance 

of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I agree to 

use a moisturizer specifically recommended by my therapist and I acknowledge that I have been informed of the 

possible negative reactions (intense erythema, welts, scabs) and the expected sequence of the healing process 

(dryness, irritation, redness, and peeling of the skin). In the event that I may have additional questions or concerns 

regarding my treatment or suggested home product/post-treatment care, I will consult my therapist immediately. 


client initials

I understand the potential risks and complications and have chosen to proceed with the treatment after careful 

consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that 

constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, 

and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any 

questions answered. 

Client Name (printed)  _____________________________________________________________________________

Client Name (signature)  ______________________________________________ Date________________________  

Esthetician _________________________________________________________ Date________________________

Associated Skin Care Professionals