Chemical Peel Consultation Form Template
A peel’s outcome is decided before the acid is ever mixed. Depth, agent, and timing are all chosen from answers the patient gives days earlier — skin’s tendency to pigment, medications in the cabinet, honesty about sun habits. This consultation form structures that decision: a repeatable clearance process that separates suitable candidates from deferred ones, and documents why.
Fitzpatrick Typing, Without Guesswork
Depth selection starts with melanin behavior, and the Fitzpatrick scale remains the working tool:
- Have patients self-identify against visual references using a picture choice question — photos communicate what descriptions blur
- Pair it with behavioral questions: how does skin respond to sun — burn, tan, or both? Reactions anchor typing more reliably than tone alone
- Record the type in the response, because every later decision references it
Types IV through VI carry elevated post-inflammatory pigmentation risk; Type I burns at low energies. The type you record today governs the agent and neutralization you choose next month.
The Contraindication Gate
Some answers defer a peel, full stop. The form checks each explicitly:
- Isotretinoin within the last six months
- Active cold sores, open lesions, or sunburn on the treatment area
- Recent waxing, laser, or another peel without adequate healing time
- Pregnancy or nursing, depending on agents used
- History of keloid scarring or abnormal healing
- Any radiation exposure to the treatment area
Build these as yes/no gates that reveal a detail field when triggered. A yes isn’t a rejection — it’s the moment to defer, document, and reschedule with a plan.
The Prep Protocol, Assigned in Advance
Peel results depend on what happens in the fortnight before:
- Pre-treatment actives where indicated — and stopping others that would sensitize skin
- Sun discipline, confirmed rather than assumed
- Baseline photographs, taken at home the week prior
Assigning the protocol through the form — with a confirmation reply the patient can keep on their phone — measurably improves compliance and outcomes.
Planning the Downtime Conversation
Patients fear what they haven’t pictured. The consultation should capture schedule realities — events in the next three weeks, public-facing work — via a short text field, so the peel depth can match the calendar. A patient with a wedding in ten days needs a different plan than one with a quiet fortnight. Documenting this protects both the result and the relationship.
Frequently Asked Questions
Can patients self-report Fitzpatrick type accurately?
With visual references and behavioral anchors, yes — self-report plus your clinical confirmation at the consult is the standard approach. The form captures the starting point; you verify in person.
Which single answer defers the most peels?
Recent isotretinoin use, followed closely by active sunburn and unhealed recent procedures. All three are captured as explicit checks because memory alone fails under appointment enthusiasm.
How should the form handle patients who want deeper results than their skin permits?
Show them the reasoning: record their Fitzpatrick type and pigment history, and explain what depth their skin tolerates safely. A documented, staged plan — lighter peels building over sessions — converts most disappointment into commitment.
Should the peel consent be separate from the consultation form?
Yes. The consultation gathers and documents; the consent records the specific procedure, its risks, and the patient’s agreement — ideally signed at the clinic after in-person assessment.