Chemical peel consent form

Vallyn Hair and Permanent Makeup- Service provided by Vallyn Nguyen

Chemical Peel Consent Form

The chemical solution is used to peel away the skin’s damaged outer layers. The new cells and collagen are stimulated during the healing process to produce a smoother, tighter, younger looking skin surface. A peel does not eliminate sagging or excess skin. Each treatment is customized for patient skin type, specific problem areas and the delicate areas of the face. The depth of the peel is dependent on the concentration and type of acid, the duration of the skin contact and a person’s skin type and sensitivity. The results are not always predictable depending on the factor below;

Please read the following information before signing:

Contraindications to all peels: If you have any of the following, a peel should not be done at this time

Active herpes simplex (cold soreFacial Warts)
If you are using Accutane in the last 6 months
If you are now pregnant, think you might be pregnant, or are trying to become pregnant
If you form keloid or hypertrophic scars
If you have a history of sun allergies
Prior bad reaction to a peel
Recent radiation treatment for cancer
Sun burn or significant sun exposure in the last two days
Surgery or cryosurgery within the last month to the area that you plan to have peeled
Allergic to Resorcinol
Allergies to salicylic acids
Blood vessel disease
Diabetes
Inflammation, irritation or infection of the skin
Influenza
Varicella (chicken pox)
Kidney or Liver disease

The results of the peel are not the same for everyone due to skin types and sensitivity.
The agent is rapidly neutralized after several minutes with another solution.
I may experience some stinging, burning, redness, irritation, and crusting.
It is common to experience some temporary flaking or scaling, redness and dryness of the skin.
I may immediately return to normal activities.
I have been instructed what to use to keep the skin clean and moist with hyaluronic acid.
I have been instructed to begin or continue a regular program of sunscreens and sun protection.
DO NOT use saunas or excessive exercise during the peeling process.
DO NOT pick, pull on the first 3 days, let the dead skin flake off on its own, give time for your new skin to mature.

What To Do Before Your Peel

Do not apply Retin-A, Renova, Tazorac, and/or Differin 2 weeks prior to and 2 weeks after your treatment, to the treatment area or as instructed by your aesthetician
Do not sun tan or use the tanning bed 2-4 weeks prior to and 2-4 weeks after your treatment.
Stop any type of depilatory treatments (waxing, depilatory creams) to the area of treatment,
2 weeks prior to and 2 weeks after your peel.
Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of
treatment, 2-4 weeks before and 2-4 weeks after your peel or as instructed by your aesthetician.

Chemical Peels Post Treatment Care

When cleansing, do not scrub. Use a gentle cleanser, no harsh chemicals or wash with warm water.
With any peel, your skin may start to peel 1-3 days after the peel and continue to peel for 2-5 more days; however, it is also possible your skin may not peel at all.
Do not peel, pick or scratch the treated area, as this may result in scarring.
Apply Healing cream or hyaluronic acid to speed up the healing process as many times as needed per day
Do not have any other facial treatments for at least 2 weeks after your peel or until the skin is
smooth and back to normal.
Always wear your sunscreen; apply a sunscreen with SPF 30 every morning or wear hat to protect your face.

After Peel: You may have tightness and smoothness immediately post-peel. Peeling usually begins 1-2 days after peeling and can extend up to 7 days. Transient hyper-pigmentation and superficial crusting is possible in areas of inflamed acne. Your skin may experience darkening after peeling due to increased shedding of the outer layers. Minor side effects may include, but are not limited to superficial crusting, edema and temporary bruising in the lower eyelid areas, hypo-pigmentation, temporary dryness and hyper-pigmentation, all which typically resolves quickly. The salon has “Skin Renewal” to help with skin recovery or use “Healing Cream” or you can resume use whatever you used before.

Chemical Peel Consent & Treatment Instructions

I acknowledge that I am obligated to follow Vallyn Hair and Permanent Makeup instructions closely and visit the office as directed. I have been given ample opportunity for discussion and my questions have been answered to my satisfaction. I’m not under alcohol or medication before signing this consent form.