GLOWDEGA Chemical Peel Informed Consent 

Do you have any medical conditions that have been previously diagnosed and confirmed by a health care professional?

Are you currently on any medications?

Do you have any allergies?

Are you satisfied with your current skin care/lifestyle routine?

I confirm that I have completed this form truthfully and to the best of my ability

I understand that the information in this form is only used to communicate information necessary to receive chemical peel(s) at Glowdega and will not be shared with any third parties.

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from the chemical peel(s) I received at Glowdega.

I have informed Glowdega of current medical conditions prior to receiving chemical peel treatmemt and have been advised to consult my primary care physician for clearance and/or prescription medication before receiving the peel treatment.

I have been informed of the potential risks with chemical peel(s) which may include: infection (bacterial or viral), scarring, temporary color change (hyperpigmentation/hypopigmentation), allergic reactions, sunburn, slow healing, purging, and heart problems.

GLOWDEGA Chemical Peel Consent

I understand this is a cosmetic procedure with risks and potential side effects, and I voluntarily wish to have the services provided with knowledge of the potential side effects.

I understand that it is completely normal to experience tightness, dryness, light irritation, and purging of the skin due to the professional exfoliation received in my treatment at Glowdega.

I understand that my failure to follow post care instructions may also lead to undesired results, complications or effects.

I agree for Glowdega professional to take photos prior to peel application and immediately after to monitor changes in my skin.

I agree to use sun protection with an SPF 50 for the duration of my peeling process.

I understand that no guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desired results. 

I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.

I acknowledge that the treatments I receive at Glowdega are completely voluntary and I release Fairy Glow Mother, LLC dba Glowdega as well as their employed skin care professionals from any liability.

GLOWDEGA Chemical Peel Informed Consent

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