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Chemical Peel Consent Form Template

A printable consent form for chemical peels, with the screening questions that change the treatment and the expectations about peeling, downtime, and sun avoidance clients need in writing.

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Last reviewed September 2026 · Not legal advice

Part of the Chemical peel treatment guide →

Set expectations about downtime

The most common peel complaint is not a complication but a surprise: more redness or flaking than the client expected. The form should describe what is normal, how long it lasts, and what not to do, such as picking or sun exposure.

Screening answers matter as much as the risks. Isotretinoin, recent retinoid use, cold sore history, and sun exposure change what you can safely do, so the form should ask and the record should keep the answers.

Clinic name · address · phone

Chemical Peel Consent Form

Client

Full name

Date of birth

Phone

Screening

Pregnant or breastfeeding? Yes No

Isotretinoin in the past 12 months? Yes No

Retinoid or exfoliating acid in the past 5 days? Yes NoIf yes, details

History of cold sores? Yes No

Sunburn or tanning in the past 2 weeks? Yes No

Tendency to scar, keloid, or hyperpigmentation? Yes NoIf yes, details

Risks and acknowledgements

Initial each item to confirm you have read and understood it.

InitialsI understand that redness, tightness, flaking, and peeling are expected and may last several days.

InitialsI understand risks include irritation, pigment change, infection, and scarring.

InitialsI agree to avoid sun exposure and to wear SPF daily.

InitialsI agree not to pick or peel treated skin.

InitialsI have disclosed all medications and skincare products.

Consent

I have had the chance to ask questions
I received aftercare instructions
I consent to treatment

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/chemical-peel-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for aestheticians.

Frequently asked questions

Does every peel need a patch test?

Many practitioners patch test for first-time or sensitive clients. Follow your protocol and record the outcome.

Can the same form cover multiple peels?

It can cover a series if it says so, but reconfirm health and medication at each visit.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.