Chemical Peel Consent Form

Prep so your peel is even and safe:

Pause retinol and exfoliating acids for 3–5 days before.
No waxing, laser, or other resurfacing on the area for about a week before.
Avoid sunburn and heavy sun exposure; reschedule with an active cold sore or breakout.
No Accutane/isotretinoin within the last 6 months.

As your skin peels and renews (this is where the magic happens):

Do not pick or peel flaking skin — let it shed naturally to avoid scarring.
Wear SPF every day — this is essential while new skin is exposed.
Skip retinol, acids, and exfoliants until fully healed.
Avoid sun, saunas, sweat, and hot showers during peeling.
Light peeling or flaking for 3–7 days is normal — keep skin hydrated.

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Section A — Client Information

First Name *

Last Name *

Phone *

Email *

Date of Birth *

Today's Date *

City

State

Postal Code

Emergency Contact Name

Emergency Contact Phone

I agree to receive booking confirmations and appointment reminders at my email address above. *

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Section B — Photo Release

I consent to before/after photos being taken for use on social media and website.

Name preference for photos

Use my name No name Fictitious name

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Section C — Medical History

List any known allergies

List all current medications

Client preferences for next visit

Additional notes for next session

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Section D — Chemical Peel Contraindications

Please check any conditions that apply to you. If any box is checked, your technician will review before proceeding.

Active cold sores, warts, or open wounds in treatment area Inflammatory rosacea or dermatitis Autoimmune disease (Lupus, RA, MS, psoriasis) Currently pregnant Recent facial surgery Currently using Accutane, Retin-A, Differin, Tazorac, or Avage Chemical peel within the past 14 days Currently using photosensitizing medications Known allergy to aspirin or salicylic acid

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Section E — Client Consent & Signature

Appointment reminders: I consent to receive appointment reminder messages via SMS. Message & data rates may apply. Reply STOP to opt out. Promotions: I consent to receive promotional and marketing messages from I Am Beautiful by Mia. Reply STOP to opt out.

By checking the SMS boxes above, you agree that I Am Beautiful by Mia may contact you at the number provided. This is not a condition of service.

Before Your Appointment

Aftercare

Section A — Client Information

Section B — Photo Release

Section C — Medical History

Section D — Chemical Peel Contraindications

Section E — Client Consent & Signature