CHEMICAL PEEL CONSULTATION & CONSENT FORM

TREATMENT OVERVIEW

We offer a curated selection of Circadia “lunchtime” chemical peels, expertly tailored to your skin's needs. Developed by Dr. Peter Pugliese, these medical-grade peels deliver visible results with minimal downtime.

• Peel Types & Benefits

  • Lactic Peel – Hydrating and gently exfoliating, ideal for dry, dehydrated, oily, or acne-prone skin. Helps strengthen capillaries and reduce redness.
  • Alpha‑Beta Peel – Combines multiple acids for gentle exfoliation, targeting fine lines, congestion, blackheads, and large pores—suitable even for sensitive or darker skin types.
  • Derma Frost Peel (Salicylic Acid) – Treats sun damage and rough texture; best suited for lighter skin tones.
  • Mandeliclear / Jessner Peel – Potent peel mixing resorcinol, lactic acid, and salicylic acid; excellent for pigmentation, sun-damage, and fine lines.

• Why Choose a Circadia Peel Treatment?

  • Customizable strengths for all skin types
  • Improves texture, tone, pigmentation, and pore size
  • Helps reduce acne and scarring
  • Results build over a course of 3–6 sessions
  • Minimal downtime: a little redness or peeling for a few days only

• Recommended Protocol

  • Typically performed in 30–45 minutes
  • We recommend a series: 3–6 sessions, spaced 2–4 weeks apart
  • Best maintained with a retinol-based or homecare regime

• Downtime & Precautions

  • Most clients experience minimal downtime—possibly light redness or peeling
  • If you’ve taken isotretinoin (Roaccutane), please wait at least 6 months before treatment

MEDICAL HISTORY

SKIN ANALYSIS & CURRENT SKINCARE

RISKS & SIDE EFFECTS

POST-TREATMENT AFTERCARE

PHOTO/VIDEO CONSENT (OPTIONAL)

CLIENT DECLARATION & CONSENT