Chemical Peel Consent Form

Chemical peels can provide marked improvement in the appearance of your skin for certain conditions. They are not, however, a “cure all” procedure. Therefore, it is very important that you have a thorough understanding of what they can and cannot do for your particular skin condition. In addition, it is imperative that you acknowledge the potential risks associated with chemical peels.

Side effects of a chemical peel may include:

Discomfort: This varies based on the type of peel used but is usually minimal and of short duration. Please ask for specific information regarding the peel you are receiving.

Swelling: This is very unusual, but if it occurs it will be minimal and subsides in a few hours to a few days.

Reddening: A red discoloration may persist anywhere from a few days to several weeks.

Demarcation: Refers to the difference in color, texture or pigmentation that may occur at the junction between the treated and non-treated skin areas.

Existing Blemishes: Moles, blood vessels (telangiectasias), freckles and sunspots may become more obvious and darker since the superficial layers of dead skin have been removed.

Eye Injury: If chemicals get into the eye, scarring and vision disturbances may occur. Protective safety glasses should be worn while chemicals are being used during the clinical procedure.

Scarring: Is very unusual, but may occur.

Pigmentation: Although extremely rare, temporary and possibly permanent changes in the color of the skin may occur.

Milia: May occur, but will disappear quickly.

Infection: Is extremely unlikely, but may occur.

Cold Sores: An outbreak of Herpes simplex may occur in affected individuals (ask your doctor about an antiviral medication if you are prone to cold sores).

Before subjecting yourself to this procedure, read carefully the following statements. Your signature indicates your agreement.

  • The clinical procedure has been explained to me by the esthetician of the spa staff and my questions have been answered.
  • I understand that the clinical procedure is a skin rejuvenation treatment and that I may need several administrations of clinical procedures in order to receive my best results.
  • I understand that for optimum results, a home treatment program may be needed to enhance the results of clinical procedures.
  • I understand that is extremely important to strictly follow all home care instructions to minimize adverse reactions and achieve optimal results.
  • I understand that if I experience any adverse side effects that appear to be attributable to the procedure or my use of home care products, I will discontinue use of the products immediately and notify the office.



Patient’s Printed Name

_____________________________________   ______________

Patient Signature Date

_____________________________________    ______________

Witness Date

Please call our office 404-609-1718 with any questions or concerns

*Click here for Facial Peel Consent Form PDF