Spa Advanced Treatment Consent Log

Captures signed consent for chemical peels and other advanced esthetic treatments, including contraindication screening and post-treatment acknowledgment.

Client and Appointment Details

• Client Name
• Appointment Date
• Provider Name
• Treatment Location

Treatment Requested

• Treatment Type
• Describe the specific treatment or product to be used
• Chemical Peel Strength
• Treatment Area

Contraindication Screening

• Are you pregnant or nursing?
• Have you used isotretinoin (Accutane) within the last 6 months?
• Have you had recent waxing, laser, retinoid use, or exfoliation on the treatment area?
• Current skin conditions or concerns
• Known allergies or sensitivities relevant to treatment
  Include only product, ingredient, or topical sensitivities relevant to the planned service.

Informed Consent and Acknowledgment

• I understand the possible risks, including redness, irritation, peeling, temporary discoloration, sensitivity, and the possibility of an adverse reaction.
• I understand and agree to follow the aftercare instructions provided by the provider.
• Alternative treatments or deferral options were discussed with me.
• I had the opportunity to ask questions and received satisfactory answers.
• I consent to receive the selected treatment today.

Signature and Submission

• Client Signature
• Signature Date
• Provider Notes
  Record any treatment-specific notes, deferrals, or follow-up instructions. Avoid unnecessary PII.