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Chemical Peel Consent Form

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of chemical peel. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment.

It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process.
A chemical peel involves the application of a chemical solution to the skin which acts to remove the top layers of the skin. The skin that regrows is smoother with improved cosmetic appearance. A chemical peel can be used to improve the appearance of lines and wrinkles, tired skin, fine scars, acne and areas of skin pigmentation.
There are 3 different types of chemical peels light, medium and deep. These relate to the different depths of skin layer removal. Deeper chemical peels take longer to heal but will tend to produce more significant results. Light chemical peels are less aggressive to the skin but may need to be done more frequently to achieve desired results. A deep chemical peel should only be done once as repeated deep peels would damage the skin.
Multiple treatments for lighter peels are often required to obtain optimal results spaced apart. Due to variables such as age, condition of your skin, sun damage, smoking, skincare products, climate, lifestyle, and general health, you acknowledge that there are no guarantees, warranties or assurances that you will be satisfied with your results. The skin can take up to 14 days to heal after a chemical peel and repeat peels should not be done within this 2 week period. You should have repeat peels at 4-6 weeks.
I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.
RISKS AND SIDE EFFECTS: As with any procedure there are risks and complications involved. It is important that you are aware of these before proceeding. I am aware of the following risks/complications that may occur:
Common side effects include, mild to moderate discomfort or pain following the procedure, slight redness or swelling of the skin following the peel, increased sun sensitivity of the skin and general increased skin sensitivity. These effects can last up to 14 days as this is the skins healing time following the peel. Occasionally skin redness may persist for longer than 14 days. Less commonly pigment changes to the skin can occur, the skin may become lighter or darker in pigment after the peel. Occasionally these pigment changes can be permanent.
Rare complications include allergic reaction to the chemical product, which could include anaphylaxis requiring emergency medical attention. Bacterial infection of the skin (cellulitis) or reactivation of herpes virus infections. Permanent scarring is also a rare possibility.
I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Before receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:
- the aims/motivations for having the procedure and the desired outcome
- the risks inherent in the procedure
- the risks inherent in refusing the procedure
- the risks specific to me
- the expected benefits of the treatment
- the potential disadvantages of the treatment
- alternative procedures and their pros and cons - including the option of no treatment at all
- any uncertainties about and the likelihood of success of the procedure
- any follow-up treatment that may be required
CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records.
I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.
I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
Date / Time
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The following aftercare advice is essential to help reduce the risk of treatment
complications, to improve your comfort/healing and to help achieve the best possible
results from treatment.
Please follow the aftercare advice for chemical peel.
• The treated area of skin may feel slightly tender and appear red and swollen
afterwards. You may occasionally experience skin peeling and appearances may
be similar to mild sunburn. These effects will resolve naturally and should be
much improved after 48 hours but may take longer to settle. You may experience
some minor bruising which may take 1-2 weeks to resolve in some cases.
• Avoid any perfumes, fake tan or other harsh chemicals for 72 hours after
• Avoid any makeup for 24 hours after treatment as this can increase the risk of
• Avoid rubbing or picking the treated area.
• Avoid any skin exfoliation for 72 hours following treatment.
• It is important to use a regular moisturising cream around two to three times a
day on the treated area. Use more regularly if you feel the skin dry or peeling.
• Avoid any products that contain alpha hydroxy acids, retinol, and glycolic acid for
at least 7 days after treatment.
• Avoid strenuous exercise, saunas, sunbeds and exposure to heat for 72 hours
after treatment. These can cause sweating which can irritate the delicate skin
and slow down your ability to heal quickly.
• Avoid swimming for 72 hours after treatment.
• Avoid any excess alcohol or caffeine for 48 hours after treatment.
• Wear SPF 30 or greater sunscreen for at least 2 weeks following treatment as
your skin will be more sensitive to sunlight afterwards.
• Avoid any further cosmetic treatments e.g. Botox or dermal filler for 2 weeks
following treatment, or ask your practitioner for advice.
• Avoid any hair removal treatments such as waxing for 2 weeks after treatment or
until the initial redness and swelling has resolved.
• You must seek medical attention and contact your practitioner if you experience
any signs or symptoms of infection after treatment. Infection can present as hot,

red shiny skin, there may be pus formation and you may have a fever or feel
generally unwell.
• You must contact your practitioner as soon as possible if you notice any other
unwanted side effects.
• Your practitioner will advise when further treatment appointments are required. If
you are advised to attend a follow up appointment, please do make every effort
to attend them. You should do this even if you believe that the recovery process
is going well and you cannot see that there are any visible complications.
It is essential that you have read all of the information available. Once you have read and
understood all of the below, please sign the declaration at the bottom of this form. Please
do let your practitioner know if you have any questions or if you do not understand any of
the aftercare instructions provided below.
I confirm that I have read and understood all the information on this Form and that I have
been given the opportunity to ask any questions that have come to mind throughout.

Date / Time