Chemical peel consultation and consent formPlease answer all questions. How did you hear about us? Full Name Date of Birth Address Contact Number Email Which practice would you like to contact? IllfordHornchurchAre you taking any medication? YesNoPlease provide list of medication: This is an informed consent document which has been prepared to assist your skincare specialist to inform you about skin peel and skin treatment procedure(s), its risks and alternative treatments. It is very important that you read this information carefully and completely.Although it is impossible to list every potential risk and complication the following conditions are recognized as contraindications for skin peel treatment and must be disclosed and discussed with the specialist prior to treatment.Do you have any of the following contraindicationRoaccutane or Accutane within the last 6 months YesNoActive herpes simplex {cold sores} YesNoFacial warts YesNoAre you currently pregnant YesNoKeloid or hypertrophic scars YesNoHistory of sun allergies YesNoPrior bad reaction to a facial peel YesNoRecent radiation treatment for cancer YesNoAllergic with salicylic acids YesNoDiabetes YesNoInflammation/irritation/infection of the skin YesNoIf you have ticked any of the above contraindication, please give details below:: Next of kin Full Name Relationship to Patient Contact Number GP Details GP Name Practice Name GP Contact Number I understand that results may vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcomeI agree that I have read and understand this consent form and all the information above. I understand that this procedure is purely elective.This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.
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