Chemical Peel/Microdermabrasion - Safety Questionnaire & Consent Renewal

Chemical peel/microdermabrasion treatments are intended to attempt to improve facial expression lines, texture, scarring, and pigmentation.

Risks, side effects, and complications are usually minimal.  Occasionally you may experience erythema, swelling, bleeding, temporary scarring, dryness and/or discomfort. It may be necessary to pre-treat you with a specific medication if you have a history of frequent cold sores. The risk of bruising or bleeding may be increased by medications with anticoagulant effects such as aspirin and non-steroidal anti-inflammatory drugs (ibuprofen, Aleve, Motrin, Celebrex), high doses of Vit. E, and certain herbs (Ginko Biloba, St John’s Wart). Treatment should be avoided by those with known keloid formation or if taking immunosuppressive therapy or diabetics. There may be an increased risk of post treatment infection and/or complications. Treatment should not be performed on skin with active cold sores, warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis, inflammatory Rosacea in the area to be treated, or an autoimmune disease.

Peeling of the skin may or may not happen. It is important that you do not pick or pull at any skin that is flaking or peeling.  Peeling can last 3-7 days and the severity of the peeling will depend on your skin condition. Lack of flaking or peeling is not an indication that the treatment was unsuccessful. If you do not notice actual peeling, you are still receiving all of the benefits of your treatment such as – improvement of skin tone and texture, the appearance of fine lines, and hyperpigmentation. There are a number of reasons why some people may not experience peeling such as – severe sun damage, having peels regularly with short intervals between treatments, and frequent use of Retin-A, Retinol, or AHA’s.

I have read and understand the risk of the treatment, the expected benefits, and alternative options, including no treatment at all. I have been given the opportunity to ask questions about my condition and the treatment and alternative forms of treatment. I understand that every effort will be made to provide a positive outcome, but there are no guarantees of results. I understand and accept the risks of the procedure, and request that it be performed on me. I hereby release the medical director, esthetician, and facility from liability associated with this procedure. I consent to this procedure today and for all subsequent treatments.


Issues in signing document?  Scroll up to see required areas marked in red that you need to fill out then re-sign.

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Chemical Peel/Microdermabrasion - Safety Questionnaire & Consent Renewal
lock iconUnique Document ID: 234d60b0401841e32a798cd1dbb3a5e89a8acce8
Timestamp Audit
May 14, 2020 1:10 pm PDTChemical Peel/Microdermabrasion - Safety Questionnaire & Consent Renewal Uploaded by Skinlogic Med Spa - IP