Facial Sculpting

Chemical Peel Profile Form


Name D.O.B Gender  

Business Name  

Address  

City Country Post code  

Phone Number Email Address  

ABSOLUTE CONTRAINDICATIONS

Are you currently using or have you used Roaccutane in the last six months?  

Are you pregnant or nursing/lactating?  

Do you have a cold sore today (herpetic breakout) ?  

Do you have any allergies? If yes please list  

Do you have a skin infection/open wound in the treatment area?  

RELATIVE CONTRAINDICATIONS

Have you had a chemical peel within the last 14 days?  

Have you had laser hair removal within the last 14 days?  

Have you had a photofacial treatment within the last 14 days?  

Have you had radio frequency skin tightening treatments within the last 14 days?  

Have you had microdermabrasion treatment within the last 14 days?  

Have you had waxing, threading, or any other form of hair removal in the last 7 days?  

Have you had Botox in the last 7 days?  

Have you had any dermal filler injections in the last 7 days?  

Have you been exposed to the sun in the last 2 weeks?  

Have you used a tanning bed in the last 2 weeks?  

Are you currently using any sunless tanning products?  

Are you using any prescription or non-prescription retinoids (eg, retinol, Retin-A, Tazorac)?  

Are you using any AHA/BHA skin care products?  

Are you using any prescription topical medications at this time?  

Do you wear contact lenses?  

Do you have permanent makeup?  

Do you participate in aerobic physical activity?  

Have you ever had a cold sore?  

Have you ever used any skin care products that have caused an adverse reaction?  

If yes, which ones?  

What is the ethnic background of your parents?  

What are the skin concerns that you would like us to help you with?  

Date  

Leave this empty:

Signed by Nina Bal
Signed On: 8th January 2020

Signature Certificate
Document name: Chemical Peel Profile Form
Unique Document ID: d638116b97c5322d9a02683b38cb2a3a997723ff
Timestamp Audit
7th November 2019 8:32 am BSTChemical Peel Profile Form Uploaded by Nina Bal - info@facialsculpting.co.uk IP 51.179.98.227