Facial Intake Form

Chemical Peel Release Form

Glo Skin Beauty peels vary in strength from superficial to light. After a thorough skin analysis your esthetician will select the appropriate peel formulation for your skin.
Todays date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
First NameLast Name
Phone

Area CodePhone Number
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact

First NameLast Name
Contact Number

Area CodePhone Number
If yes, when?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any specific concerns regarding your skin?
Are you presently using or recently used (past 5-7 days) any of the following. Check any that apply:
Have you ever received any of the following treatments
Have you had recent prolonged sun exposure in the last 14 days?
Are you willing to abstain from extended sun exposure and wear SPF 15 while outdoors for the next 3-5 days?
Known allergies or sensitivities (food, botanical, none,etc)
Date of last menstruation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For the next 24-48 hours after chemical peel:
- Avoid direct sunlight as skin is more vulnerable to UV damage
- Wear SPF 15 or greater when outside
- Avoid very hot showers, steam, or sauna as it may cause post-inflammatory conditions.
- Refrain from picking at peeling skin and allow skin to slough on its own.
Signature
Please verify that you are human
Should be Empty: