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Glycolic Acid Medical Release Form
First Name: Last Name:
Street Address: Phone Number: Cell:
City: State / Province: Postal Code:
I understand that I am going to have a light Glycolic Acid (alpha hydroxy acid) peel. I understand that this is a superficial
type of peel that normally creates, at most, only 1 or 2 days of mild redness with occasional areas of flaking skin.
My skin care professional and I have reveiwed the information below:
Accutane: It is not advisable to perform the procedure if Accutane has been used within 6 months.
(Accutane dramatically reduces the size of your sebacious glands and thus affects the skins natural ability to heal itself. The chance of
scarring is much higher if a chemical peel is performed while taking Acutane or too soon after treatment.)
Renova, Retina A: It is not advisable to perform the procedure if Renova, Retina A has been used
Allergies: Multiple allergies may suggest sensitive skin and the potential of a reaction.
Antibiotics medication: The procedure may be inadvisable due to a potential of a reaction.
Autoimmune Disease: The procedure may be inadvisable due to a potential of a reaction.
Cuts, Abrasions, and Scrapes: delay procedure until the skin has healed.
Eczema: Suggests sensitive skin and possible reaction.
Fever Blisters: The procedure may stimulate fever blisters if there is a propensity for them.
Hair Dying or Permanent: Due to skin irritation from these procedures it is advisable to delay peel procedures.
Herpes: Peel Procedures should not be performed during an active outbreak of herpes in the treatment area.
Keloidal or Pigmented Scarring: Procedure is not advisable.
Lesions of Potentially Malignant Pigmented Nature: Procedure is not advisable.
Recent Medical Treatment: Procedure requires physician’s consent if radiation, laser, cryo, electro or injection.
Pregnancy or Lactating: Procedure should not be performed during pregnancy or lactating.
Seborrhea: Suggests sensitive skin and possible reaction.
( inflammatory skin disorder affecting the scalp, face, and torso. Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin.)
Sunburn: Due to existing skin irritation it is advisable to delay procedure for several days.
Surgery or Trauma: Delay procedure until recuperation is complete.
Tattoos: Procedure should not be performed for several weeks in areas involving recent tattooing.
Tobacco: Healing of smokers may be slow, especially around the mouth.
Warts: Due to possibility of spreading the wart virus, the procedure is not advisable in areas with warts
Sunburn alert! This product contains alpha hydroxy acid (AHA). Increased sun burn risk. Must use SPF 30+
I am undergoing this peel in an effort to improve my skin texture and color. I understand I could achieve some improvement in my fine wrinkles as well, but
no guarantee has been made to me regarding my level of improvement from this peel. My skin care professional has explained to me that I may need
several peels to achieve best results.
Treatment #1 Date
Guardian / Witness Date
Treatment #2 Date
Treatment #3 Date
Treatment #4 Date
Treatment #5 Date
Treatment #6 Date
Treatment #7 Date
Treatment #8 Date
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
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Client Chemical Peel Cautions and Information (Glycolic Acid)
A skin peel is a complex procedure with certain inherent risks. If you follow your skin care professional’s
advice and directions, the risk of complications in this procedure is minimal. Anything that you do against
your skin care professionals advice increases the chances of your having complications.
Because of the superficial nature of this peel, you should not expect to really “peel”. Most patients who
undergo this therapy have only a little redness for 12 to 24 hours. Occasionally, they may have very slight
flaking in a few localized areas for 1 to 2 days. In rare instances, an area of crusting may develop. If this
occurs, apply a small amount of vaseline to the area. The idea is to keep you from picking and to allow time
for the skin to slough on its own, vaseline will protect and allow for this time to occur.
It is extremely important that you do not pick, scratch, pull or rub your skin during or after your peel. If
you do, you may damage the underlying new skin and cause scarring or changes in your pigmentation.
You will be well informed as to what you can and cannot do during post peel healing period. There are certain
conditions that may require postponement of your peel today, these include:
• Inflamed acne lesions
• Open cuts or scratches on your face
• Active cold sores on lips and or face
• Any facial surgery within 3 months
• In addition, if you are under severe physical or mental stress, it is not a good time for a peel. It is important
that you can devote all of your energies to your peel and are not distracted by other physical or mental
needs.
For the first 24 hours after you have received your chemical peel, please adhere to the following:
• Sleep on your back if possible
• A fresh, clean pillow case should be used
• Shower with caution, do place face directly toward showerhead
• Avoid extensive exercise, sun or tanning beds, and any hot water including saunas, Jacuzzis or hot tubs
• Avoid chemical hair treatments such as hair color or perming
No waxing, microdermabrasion, or other exfoliation treatments not provided by your current skin care spe-
cialist for the duration of your treatments and up to 2 weeks after your last.
Use only the post peel products provided by your skin care specialist for 3 to 4 days following your peel then
return to your regular skin care regime.
Avoid sunlight for the duration of your treatments and use sunscreen if sun avoidance is not possible.Please
realize that these warnings are for your protection. It will be your responsibility to follow this advice since you
will be caring for your skin at home. The motto in this office is if you are not sure if you should do something
or don’t understand the directions, call the office before you do anything!
Print Name Signature Date
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
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Client Consent for Professional Exfoliating Peel
Thoroughly read this consent form. Initial each section and sign and date the bottom. If you have any
questions, discuss them with your skin care professional.
I have reviewed and completed the proper Serene pre and post peel documents with my skin
care therapist. I do not have any conditions that would prevent or require a doctor’s consent to
have a Professional Exfoliating Peel. I have reviewed the conditions that may suggest a reaction
or slow healing and I am aware of his possibility. I have signed and dated the Medical Form.
I acknowledge the possibility of allergic reaction, and that neither Serene or my skin care therapist
are responsible for such a reaction or any medical care that may be necessary in the unlikely event
of such reaction.
I acknowledge that the use of Serene home use glycolic products for a minimum of two weeks
and an Professional Exfoliating Peel patch test do not necessarily negate the possibility of an
adverse or allergic reaction.
I will not pick, peel, or use an abrasive product on the treated skin area for several days following
the Professional Exfoliating Peel treatment since these actions could potentially lead to an infec-
tion of pigmented areas.
I understand that my skin may look red or darker, rough, and/or dry for several days following the
Professional Exfoliating Peel as the outer layer is sloughed off.
I understand that I should avoid direct sun exposure and/or tanning booths for several weeks
following the Exfoliating Peel, and that I must protect my skin with Serene ‘UVA UVB Shield’.
I understand that I could potentially feel a slight tingling, burning or prickling sensation during the
procedure and immediately following the procedure, this will gradually subside.
I understand the above, and under these conditions, give my consent to have a Professional
Exfoliating Peel performed.
Patient Signature Date
Parent Signature (Undere 18) Date
Witness Date
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
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FITZPATRICK SKIN EVALUATION
0 1 2 3 4 SCORE
Light Blue Blue
What is the Dark Blue or Dark Brownish
color of your eyes? Gray Gray
Hazel Brown Black
Light Green Green
What is the natural Chestnut Dark
Sandy or Red Blonde Black
color of your hair? Dark Blonde Brown
What is the color Light
of your skin? Pale with
Reddish Very pale Dark Brown
(non-exposed area) Beige Tint Brown
Do you have freckles on Many Several Few Incidental None
unexposed areas?
What happens when you Painless redness, Blistering followed Burns sometimes
stay in the sun too long? blistering, peeling by peeling followed by peeling Rarely burn Never had burns
To what degree do you Turns dark
turn brown? Hardly or not at all Light color tan Reasonable tan Tans easily brown quickly
Do you turn brown
within several hours after Never Seldom Sometimes Often Always
sun exposure?
How does your face Never had
react to the sun? Very sensitive Sensitive Normal Very resistant a problem
When was the last time
you exposed your body to More than 3 2-3 1-2 Less than a Less than 2
the sun, tanning bed or months ago months ago Month(s) ago month ago months ago
self-tanning cream?
How frequently do you
expose the area to be Never Hardley ever Sometimes Often Always
treated to the sun?
Total Score
The Fitzpatrick Scale (a.k.a. Fitzpatrick skin type test or Fitzpatrick phototyping scale) is a numerical
classification schema for the color of the skin. It was developed in 1975 by T.B. Fitzpatrick, a Harvard
dermatologist, as a way to classify the response of different types of skin to UV light. It remains a recognized
tool for dermatologic research into skin of color.
It measueres several components: Genetic Disposition, Reaction to Sun Exposure and Tanning Habits
The Fitzpatrick Scale:
• Type 1 (Scores 0 - 7) White / Subject to sunburn
• Type 2 (Scores 8 - 16) Tan / Capable of tanning
• Type 3 (Scores 17 - 25) Dark / Capable of tanning
• Type 4 (Scores 25 - 30 ) Dark
• Type 5 - 6 (Scores over 30) Very Dark
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
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Day of Peel Checklist
Patient Name: Date:
Has the patient signed the consent form and medical release: __ Yes __ No
Have photographs been taken: __ Yes __ No
Have woods lamp finding been recorded: ___ Yes ___ No
Has the client discontinues use of Retinal A products:___ Yes ___ No
Does the patient have a quiet week coming up: __ Yes __ No
Does the patient have any unanswered questions about the peel: __ Yes __ No
After care instructions gone over with the patient: __ Yes __ No
Has the client signed and received her Post Peel Recommendations: ___Yes ___ No
Has the client received a post peel product kit and instructions for use? ___Yes ___No
Remind patient for the first 24 hours:
_____ Sleep on back (on clean pillow case)
_____ Shower with caution and avoid saunas and hot tubs
_____ Minimize facial expressions
_____ No excercising
_____ No picking
_____ Avoid Sunlight
____ Avoid chemical hair services (hair coloring and perming)
_____ Call if they have any questions or concerns
Patient Signature Date
Parent Signature (Undere 18) Date
Witness Date
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
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Skin Assessment Form (Basic)
First Name Last Name Date
SKIN SENSITIVITY SKIN TEXTURE
<<<<< None I Very >>>>> <<<<< Fine I Granular >>>>>
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
SKIN TONE COMPLECTION
<<<<< None I Firm >>>>> <<<<< Clear I Pigmented >>>>>
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
ACNE GRADE NOTES
__ Grade I
__ Grade II
__ Grade III
__ Grade IV
__ Grade V
__ Grade VI
OILY
__ Normal
__ Mild
__ Severe
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
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Client Record Post Procedure Sensitive Areas
First Name Last Name Date
During a facial peel there will be areas that remain red or look irritated. This is should be noted and tracked during multiple
peel programs (3 - 6 peels over a set period of time). This record will allow you to keep track of areas that need special atten-
tion as you ncrease percenatge and or lower pH. Your client’s skin can and will be different every time you peel and precise
records will help you assess the proper next step or areas that could be cause for concern.
Date: Date:
Chemical Peel: Chemical Peel:
Percentage: Percentage:
pH: pH:
Elapsed Time: Elapsed Time:
Date: Date:
Chemical Peel: Chemical Peel:
Percentage: Percentage:
pH: pH:
Elapsed Time: Elapsed Time:
Directions: Mark any way you like that will help you identify areas that need special attention. Best practice is to use a differ-
ent color highlighter of your choosing for different skin issues you would like to track.
SkinCareScience, Inc. 2426 Townsgate Road, Suite 500 Westlake Village, CA 91362 O: 805.497.4600 O: 800.865.0167 F: 888.908.5160 skincarescience.com
