Consultation Form: AHA Chemical Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice both prior to and post-treatment. Please read the following information prior to booking an appointment in the salon. Consultation Information: to ensure you are not contraindicated to any treatment. Pretreatment Advice: should be read prior to attending an appointment. Aftercare Advice: to be read following your appointment for best results. Children under the age of 16 should have consent from a parent or guardian prior to any appointment. CONSULTATION FACIAL PEEL Advanced AHA Cosmeceuticals Do you currently have any of the following?
Psoriasis Eczema Dermatitis Open Active/Cystic Acne Cold Sores/Fever Blisters Sensitive Eyes Hyper Sensitive/Reactive Skin If yes to any of the above, do not have a peel until any breakout/sensitivity has fully cleared. Asthma Bronchitis Hay Fever If yes, please inform your practitioner; you may be more sensitive to the treatment. Do you have any other skin conditions? Yes/No If yes, explain: Do you have any allergies? Yes/No If yes, to what: Have you ever had a reaction to any medication? Have you ever had a reaction to any cosmetic, hair or salon product? Are you taking any prescribed medication for acne such as Roaccutane? Yes/No If yes, a 6-month wash out period is required before a treatment can commence. Are you using any topical skin preparations from your doctor? Steroid Cream Retin A Topical Antibiotic Other
If yes, please commence treatment after your medication course has come to an end. Are you on any prescribed medication? Are you taking any supplements? Please list: Are you pregnant or nursing? Yes/No If yes, no treatment can be performed Have you had any of the following in the last six weeks? Laser Resurfacing Microdermabrasion Facial Peels/Resurfacing Injectables Facial Laser Hair Removal Ensure skin has normalized before commencing treatment Are you currently under undue stress? Have you recently been on a sunshine holiday or exposed to wind/snow etc.? Yes/No Has your lifestyle changed dramatically recently with any noticeable skin changes? Have you had any changes in your beauty routine recently? Skin Indications for the Peel (Reasons to have the peel) Acne Acne Scarring Hyper-Pigmentation Fine Lines Dry/Dehydrated Skin Photo Aging Improve Skin Texture Blocked Pore/Follicles
Any other skin conditions/concerns: Pre Chemical Contraindications (peel should not be performed) Active Herpes Inflamed Acne Cysts Pregnant or Nursing Severe Physical or Mental Distress Retin A/Reoccutane Use Radiation/Chemotherapy Open Wounds Allergy to Asprin (Salycilic Acid) Sunburn Irritated Damaged Skin Reaction To Priori Homecare Priori Product Prior Use Ideally the following skin acclimatization programme must be undertaken before your first peel. To enable an AHA peel treatment, AHA cleanser and Skin Renewal cream is recommended. Please confirm that you have been using priori skincare for at least two weeks prior to this treatment and which products you have used: Have You Had Any Of The Following Procedures In The Last 48 Hours? If so, Advanced AHA Peel cannot be performed Clay Masks Self-Tanning Agents Hair Removal Retin A or Vitamin A Product use Please ensure: The skin care specialist has explained the peel and contraindications of this form to me and I fully understand and agree with the
consultation. I understand a mild redness or slight irritation may occur temporarily and subside. I must wait 48 hours before using Advanced AHA Smoothing Eye Cream, Facial Perfection Gel and Skin Renewal Cream and 24 hours before using any other Advanced AHA homecare or other skincare products. I understand the maximum results from a peel will be achieved with a course- generally 6 peels, in conjunction with homecare products. I understand due to the variable nature of the skin, no guarantee can be made to me regarding the results of treatment. I confirm that I have a copy of the pre and post peel instruction sheet. On completion of this consultation card you must tick the Consent Box in order for the treatment to take place. By ticking the box, you are agreeing to the following terms and conditions. I accept that any treatment I have has been fully explained to me and will be undertaken at my own risk. I have carried out a patch test (where necessary) and I am satisfied with the explanation of the procedure and the aftercare. I have answered the questions regarding my medical history to the best of my knowledge and accept that failure to disclose relevant information may impact treatment results. I agree to contact Sutherlands Hair and Beauty immediately in the event of any adverse effects. I agree to these terms and conditions (Please tick)