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Consent Form

Please complete this consent form before your Chemical Peel appointment. Once you sign, a copy is emailed to you and to Gemma automatically.

Your details

Chemical Peel — treatment information & disclaimer

A chemical peel applies a solution to the skin to exfoliate and improve texture, tone, fine lines, pigmentation and clarity. Layers are tailored to your skin. Multiple treatments spaced weeks apart are usually needed and results vary between individuals; there are no guarantees of outcome.

Risks include mild to moderate discomfort, redness, swelling and peeling, increased sun sensitivity, skin sensitivity, and changes in skin pigmentation. Less commonly, scarring, allergic reaction or infection can occur.

You must follow all pre- and post-treatment instructions, including sun protection, to reduce risks. Please disclose any condition that may affect the treatment before we proceed.

A non-refundable deposit is required to secure your appointment. The balance is payable at your appointment. Deposits and booking fees are non-refundable unless agreed with the practitioner.

Medical screening

Please answer honestly — this keeps your treatment safe. Add detail in the notes where relevant.

1. Are you pregnant, breastfeeding, or trying to get pregnant?
2. Do you have any medical conditions? If yes, please give details.
3. Are you taking any medication (including blood thinners such as Warfarin/Aspirin)? If yes, please list.
4. Do you have any allergies, or have you ever had anaphylaxis? If yes, please give details.
5. Do you have any skin or neuromuscular disorders?
6. Do you have diabetes, an autoimmune disease, or a bleeding/clotting disorder?
7. Do you have a history of keloid or hypertrophic (raised) scarring?
8. Do you have any active infection, cold sores, or inflammation at the treatment area?
9. Have you had this or a similar treatment before? If so, did you have any problems?
10. What are your aims and motivations for the treatment / desired outcome? Please give details.
11. Is there any other medical or social history we should know? Please give full details.
12. Do you understand the information provided and feel it is sufficient for you to consent?
13. Has your consent been given freely?

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