PDF to Web Form

Chemical peel consent form

Peel depth, skin type and the two screening answers that decide whether it goes ahead — recorded before the solution is mixed.

Free, no account needed, 100 replies a month.

Or download the printable PDF. Free, no email address, ready to print and pin up.

The form people fill in, and the list you get back

Chemical peel consent

22 questions · takes about 6 min · preview, not fillable here

Peel being performed
Area to be treated

Select all that apply.

Fitzpatrick skin type
Do any of these apply to you?

Select all that apply.

In the last two weeks have you had any of these?

Select all that apply.

I consent to before and after photographs
Client's signature
Sign above with your finger or mouse

By signing here I agree that this signature, and the answers submitted with it, are mine and have the same effect as a signature on paper.

You can reword any of these questions, or add your own, after you create it.

An example of what you see when answers come in, with three replies
19 Aug, 16:09Wen Li1995-10-03(312) 555-0175wen.li@example.com2026-08-21A. Duarte, RNSuperficial — salicylicFull face, BackIV — rarely burns, tans easilyNone of theseWaxing or threading in the areaSpironolactoneAspirin — mildYesYesYesYesYesYesNo2026-08-19
18 Aug, 12:31Daniel Kovács1982-08-11(773) 555-0129d.kovacs@example.com2026-08-20S. Petrova, LEMedium — TCACheeks, ForeheadII — usually burns, tans minimallyCold sores or a history of herpes simplexRetinol, tretinoin or acid activesTretinoin, paused three days agoNone knownYesYesYesYesYesYesYes, and they may be used in marketing2026-08-18
18 Aug, 07:55Grace Adeyemi1990-01-24(312) 555-0143g.adeyemi@example.com2026-08-19S. Petrova, LESuperficial — mandelicFull faceV — very rarely burns, tans very easilyNone of theseNone of theseAzelaic acid 10%None knownYesYesYesYesYesYesYes, for my clinical record only2026-08-18

Scroll sideways for the rest of the 22 answers, and press any heading to sort by it. In your own form you can search the answers as well, and download them as a spreadsheet at any time.

Fitzpatrick is a consent question, not a form field

Skin type changes what peel is appropriate and how likely post-inflammatory hyperpigmentation is. A client with type V or VI skin who develops pigmentation after a peel they were not warned about has a legitimate complaint; the same client, warned in writing, has a known and disclosed outcome.

Ask it plainly and include a "not sure", because a client guessing is worse than a client admitting they do not know and letting the provider assess.

Cold sores are the one screening answer people forget

A peel can reactivate herpes simplex, and a client who last had a cold sore two years ago will not think to mention it. Naming it on the checklist is what turns it into an answer, and it is the answer that decides whether antiviral prophylaxis is needed before treatment.

Isotretinoin within six months is the other stop. Everything else on the list changes the peel selected rather than whether one happens.

Record the peel and the depth, every time

A glycolic superficial peel and a medium TCA peel are different treatments with different consent implications, and a record that says only "chemical peel" is not much of a record. Naming the agent and the area also gives the next appointment a starting point rather than a guess.

Not picking is the aftercare instruction that matters

Almost every peel scar is a picked peel. It is worth its own signed line rather than being one bullet in an aftercare leaflet, because the client who picks is usually the client who did not read the leaflet.

Sent ahead, this form answers itself better

"What actives are you using?" is a question a client can answer accurately at home with the bottle in their hand, and cannot answer accurately in a treatment room from memory. A link sent with the appointment confirmation gets the real answer.

If your practice has a consent form it already uses, upload that PDF and the questions are read off it — the wording stays as approved, and it becomes a link and a spreadsheet.

Check your state's rules

Peel depth and agent concentration limits for estheticians, and the supervision required for medium-depth peels, are set by state boards and differ significantly. This is a starting point, not a compliance document.

Questions people ask

What should a chemical peel consent form include?

Client details and treatment date, the peel agent and depth, the area, Fitzpatrick skin type, screening for isotretinoin, herpes simplex, pregnancy, keloid history and active skin conditions, recent treatments and actives, allergies, acknowledgement of peeling and downtime, the pigmentation risk in deeper skin tones, an agreement not to pick, sun protection, aftercare and a dated signature.

Why does a chemical peel consent form ask about cold sores?

Peels can reactivate herpes simplex. A client with any history usually needs antiviral prophylaxis started before treatment, and most clients will not raise it unless asked directly.

How long does skin peel after a chemical peel?

Typically three to seven days for a superficial peel, longer for medium depth. It is worth acknowledging in writing before treatment, because unexpected flaking is the most common complaint after a first peel.

Do darker skin tones need a different consent conversation?

The risk of post-inflammatory hyperpigmentation is higher in Fitzpatrick types IV to VI, which is why the form records skin type and carries a separate acknowledgement that this was discussed rather than folding it into a general risk line.

Is this chemical peel consent form free?

Yes. Download the PDF with no account and no email address, or send the online version ahead of the appointment.

Ready to send it out?

Every question above is already written. Make it a form, get your link, and send it. Reword anything first if your group asks it differently.

Free, no account needed to start, and the printable PDF stays one click away.

Already have your own version of this form?

You build nothing. Drop the PDF here, or photograph the printed copy, and the questions are read off it: no canvas, no dragging a box onto each field, no mapping step. The wording your organisation already approved stays exactly as it is, and you get a link that collects the answers back as a spreadsheet — and as the original document, filled in.

Related templates

All free form templates · Salons, spas and studios