Skincare Treatment Profile and Consent

Preparing for Your Professional Treatment

Please follow the outline below to prepare for your treatment:

Fourteen days prior to your appointment, refrain from:
- having a chemical peel.
- tanning in a tanning booth. This practice should be discontinued altogether, due to the increased risk of skin cancer and signs of aging.
- having a wax or chemical depilatory treatment (five days prior).
- getting neurotoxin or dermal filler injections (two days prior).
For best results and to reduce the risk of complications, it is recommended that patients use PCA SKIN® daily care products 10 to 14 days prior to treatment.
It is recommended that extended sun exposure be avoided, especially in the 10 days prior to treatment.
It is recommended to delay use of tretinoin, Retin-A®, Renova®, Differin®, Tazorac®, Avage®, EpiDuo®, Ziana®, and high-percentage AHA and BHA products for approximately five days prior to treatment. Consult your physician before temporarily discontinuing use of any prescription medications.

Patient Profile and Consent Form

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Patient Profile

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Age*

Sex*

Female

Male

Address*

Street Address City State ZIP Code

About You

What is your hereditary background? (check all that apply)*

Nordic

Scandinavian

Irish

English

Asian

Mediterranean

Hispanic

Native American

Middle Eastern

African American

Other

Natural eye color:*

Natural hair color:*

Do you consider your skin (check the best option):*

Sensitive

Resilient

Unsure

Describe your skin (check all the apply):*

Normal

Dry

Three

T-Zone/Combination

Thick

Thin

Saggy

Firm

Oily

Acne

Comedones/Blackheads

Milia

Cysts

Breakouts

Acne-Scarred

Large Pores

Small Pores

Rosacea

Eczema

Freckled

Sun-Damaged

Melasma

Hyperpigmentation

Hypopigmentation

Uneven/Blotchy

Mature

Wrinkled

Patchy Dryness

Sallow

Psoriasis

Dehydrated/Lacking Moisture

Asphyxiated

Telangiectasia/Broken Surface Capillaries

What are the changes you’d most like to see in your skin?*

Lifestyle

Are you pregnant or lactating?*

(Please consult with your obstetrician.)

Yes

Do you wear contact lenses?*

(Remove contacts if eyes are sensitive or if having microdermabrasion.)

Yes

Do you currently have a sunburned/windburned/red face?*

Yes

If yes, why?*

Are you in the habit of going to tanning booths?*

(If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)

Yes

Do you participate in vigorous aerobic activity or sports?*

Yes

If yes, what type?*

Do you smoke or use tobacco?*

Yes

What kind of work do you do?*

On average, how many hours per week do you spend outdoors?*

Medical/Treatment History

Do you currently use depilatories or wax?*

(Discontinue use five days pre- and post-treatment.)

Yes

Have you had a chemical peel or any type of procedure with a medical device?*

Yes

Within the last 14 days?*

Yes

If yes, what type?*

Do you have regular collagen, Botox® or other dermal filler injections?*

(Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.)

Yes

Have you recently had laser resurfacing or facial surgery?*

Yes

If yes, describe:*

If yes, when:*

Are you currently taking any medications, topical or otherwise?*

(Tretinoin/Retin-A®/Renova®/Differin®/Tazorac®/Avage®/ EpiDuo®/Ziana®)

Yes

If yes, which one(s)?*

If yes, for how long?*

If yes, what strength?*

(High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment. Consult your physician before discontinuing use of any prescription.)

Have you ever undergone Accutane® therapy (isotretinoin)?*

(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.) (If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel®, Sensi Peel®, Advanced Treatment Booster, Oxygenating Trio®, Hydrate: Therapeutic Oat Milk Mask, or Revitalize: Therapeutic Papaya Mask or Detoxify: Therapeutic Charcoal Mask.)

Yes

Do you develop cold sores/fever blisters?*

Yes

If yes, last breakout?*

Are you allergic/sensitive to (check all that apply):*

milk

apples

citrus

grapes

aloe vera

aspirin

perfumes

latex

hydroquinone

mushrooms

none

other

If "other" selected, what allergies?*

Have you ever used any other products that caused a bad reaction?*

Yes

If yes, describe:*

Patient Consent

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral retinoid treatments such as: tretinoin, Retin-A®, isotretinoin, Accutane®, Differin®, Tazorac®, Avage®, EpiDuo® or Ziana®.

Patient Consent*

I understand there may be some degree of discomfort such as stinging, pin-prickling sensation, heat or tightness. *

I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc. *

I understand I may or may not actually peel and that each case is individual. *

I understand that the amount of peeling does not correlate with degree of improvement. *

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied. *

I understand that to achieve maximum results, I may need several treatments. *

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the physician/clinician who performed the treatment. *

I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment, and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging. *

I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum SPF of 30 is mandatory. *

I have not had any other chemical peel of any kind within 14 days of this treatment. *

I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location. *

I understand that I should follow my clinician’s recommendations for post-procedure skin care to minimize side effects and maximize results. *

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-peel care instructions as I am directed. *

Electronic Signature*

Email*

Date*

MM slash DD slash YYYY

Comments

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