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
First NameLast Name
Phone *

Area CodePhone Number
Date of birth*

MonthDayYear
Email*
Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact *

First NameLast Name
Contact Number

Area CodePhone Number
If yes, when?

MonthDayYear
Date
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:*

Retinol or Retin A or RenovaGlycolic or Lactic AcidSalicylic AcidBenzoyl PeroxideIsoretinoin (Accutane)AntibioticsNONE
Have you ever received any of the following treatments*

MicrodermabrasionChemical PeelsBotox or any fillersLaser treatmentsNONE
Have you had recent prolonged sun exposure in the last 14 days?*

YesNo
Are you willing to abstain from extended sun exposure and wear SPF 15 while outdoors for the next 3-5 days?*

YesNo
Known allergies or sensitivities (food, botanical, none,etc)*
Date of last menstruation

MonthDayYear
Date
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

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Please verify that you are human*
Should be Empty:

Chemical Peel Release Form