Important Forms & Instructions

Chemical Peel & Microdermabrasion Forms

Chemical Peel & Microdermabrasion Consultation Form

New Patient Form

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  • Please make sure to inform us of any Retin A, Accutane, Antibiotic, St. Johns Wort or any other drugs that may cause Photosensitivity

  • Do you use sunscreen in your skincare regimen?
  • History of Keloid/Hypertrophic Scars?
  • Is there any chance you could be pregnant or are you breastfeeding?
  • Permanent cosmetics or tattoos:

Chemical Peel & Microdermabrasion Consent Form

Consent For Chemical Peel Treatment

  • Topical Exfoliants

    Our chemical peels are topical exfoliants applied to the skin to soften the dead skin layer and exfoliate the skin. Stimulating cell turnover will help to restore the skin to a more youthful appearance. Many skin conditions can be improved when receiving a series of peels.

  • Chemical Peel Benefits

    Chemical peels can soften fine lines and acne scarring. Dull skin can appear brighter and blotchy sun damaged skin may even out.

  • PRE and POST Treatment Instructions

    I have been given the PRE and POST treatment instructions sheet and will follow these instructions. I will inform the technician if I have not been able to follow these instructions.

  • Redness

    I understand that it is common and expected that the skin will be red, possibly itchy and /or irritated. It is also possible that other adverse experiences may occur such as acne, rash, swelling and burning as well as burns scars and hyper or hypo pigmentation. While most adverse reactions are rare and most can be avoided by following the Pre and Post treatment instructions, there is a risk that some conditions could be permanent. I understand and accept that risk.

  • Reaction

    I understand that all skin reacts to treatments in some manner, and agree that I will notify the Manager as soon as possible if I experience a reaction that does not resolve within several hours or becomes progressively worse after leaving. I agree to follow all care instructions given by Beauty Oasis RX and understand that I will achieve optimal healing by following all home care instructions.

  • Existing Conditions

    Existing conditions, such as herpes, acne, eczema, folliculitis, hidradenitis, psoriasis and dermatitis may flare up after a laser treatment, this may be minimized by beginning prophylactic treatment a few days before each appointment. I will advise the tech before treatment if I have any skin conditions. I understand and accept that Beauty Oasis RX will not be responsible if I fail to give this important information.

  • Sunblock SPF 30 or Higher

    I agree to use a moisturizer and sunblock SPF 30 or higher specifically recommended by my esthetician and I acknowledge that I have been informed of the possible negative reaction that may occur otherwise.

  • Exposure to the Sun

    I understand that my skin will be more sensitive to the sun and should limit any exposure to the sun. I understand and accept the risk otherwise.

  • Record Photographs

    I consent to the use of photographs for record keeping purposes; these photographs may be taken before, during and after my treatments.

  • Public Photographs

    I consent to the use of these photographs for providing information to other clients and to the public about my treatment. They may be shown during client consultations, as well as public promotional lectures and demonstrations, and may be reproduced in educational, instructional and promotional literature and on the Beauty Oasis RX website. My identity will not be compromised.

  • Physician

    I understand that a physician will be available for evaluation and follow up issues. Determination for an appointment with a physician will be made in consultation with management and myself.

  • Pregnant or Breastfeeding

    I confirm I am not currently pregnant or nursing and agree I will inform the technician if I do become pregnant, or am nursing in the future. I understand I cannot receive laser treatments while pregnant or breastfeeding.

  • This Information

    I have read and understand all the information presented to me before signing this consent. I understand the risks of side effects, despite proper treatment, exist in all cases, but can be greatly reduced by following the pre and post treatment instructions given to me. I understand the purpose of the procedures. I further understand that treatment results will vary between individuals and treated areas. I understand that there are many variables that may affect my treatments and that I have been made no promises of any results.

  • Cancellation Fee

    Beauty Oasis RX prides itself on our ability to offer the highest quality laser hair reduction at the lowest possible cost. “No Shows” and “Cancellations” create a significant burden on our ability to maintain our low prices. Therefore, clients will be automatically charged a cancellation fee of $49 for 30 min. or less appts, or $75 for appointments greater than 30 min. if not cancelled at least 24 hours in advance.


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