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Chemical Peel Consultation Form

Gather a patient's skin and medical history before a chemical peel session, including prior conditions, allergies, and medications, to assess their suitability for treatment.

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Page 1

Name

Nombre

Apellido

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Date of Birth

Please Check the Conditions You Have

Acne Rosacea Eczema Psoriasis None

Do You Have Any of the Following?

Diabetes Clotting Disorder Herpes Heart Disease None

Do You Have Skin Conditions Other Than Specified Above?

Do You Have Allergies? If Yes, Please Specify

Have You Ever Had a Reaction to Any Cosmetic, Hair, or Salon Product?

Are You Taking Any Prescribed Medication for Acne Such as Isotretinoin?

Yes No

Are You Using Any Topical Skin Preparations Such as Steroid Cream, Retin A, or Topical Antibiotic?

Yes No

Are You Pregnant or Currently Breastfeeding?

Yes No

Please Check if You Have Had Any of the Following in the Last 2 Months

Intense Sun Exposure Artificial Tanning Chemical Peel Retinoid Use

Have You Had Any of the Following Procedures in the Last 48 Hours?

Waxing Threading Shaving Laser Hair Removal

Page 2

Initials

Page 3

Initials

Signature

Sign here

Date Signed

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