OrganoPEEL® · The Peel Room

Herbal Peel Consent Form

Please complete this form before your appointment. All information is kept strictly confidential and helps us ensure your treatment is safe and tailored to your skin.

3–6 sessions recommended · 4 weeks apart

Fields marked * are required

STEP 1 OF 4

Personal Details

Your basic information so we can confirm your booking and keep our records accurate.

Full Name *

Date of Birth *

Used to confirm your age and suitability for treatment

Contact Number *

We'll use this to confirm your appointment

Home Address

Your full address including postcode

Area Being Treated

Which area would you like treated?

Previous Medical History

Any conditions, surgeries or diagnoses we should know about

STEP 2 OF 4

Health Questions

Tap YES or NO for each question. This helps us confirm your treatment is safe for your skin.

Do you suffer from any allergies?

Do you suffer from herpes simplex? (on a regular basis)

Do you suffer from any illness?

Do you suffer from eczema?

Are you currently being treated by a dermatologist? If yes, please describe below.

Are you currently taking or using any hormone medication? (e.g. the pill, HRT for menopause)

Are you currently taking or using any Cortisone tablets or creams?

Are you taking Vitamin A in tablets or using Vitamin A cream?

Are you currently using AHAs or had any AHA treatments?

Have you ever had laser treatments? If yes, please state when below.

Are you taking any regular medication?

Have you had anti-wrinkle injections before? If so, how long ago?

Are you pregnant or breastfeeding?

Are you happy to have pictures posted on our social media platform?

STEP 3 OF 4

Additional Notes

If you answered YES to anything above, please give us more detail here.

Extra details, medication names, treatment dates or anything else we should know

STEP 4 OF 4

Declaration & Consent

Please read the below carefully before ticking the box. By submitting this form you confirm that all information provided is accurate and complete to the best of your knowledge. You understand the aftercare requirements — including keeping your face dry for 7 days post-treatment — and consent to the OrganoPEEL® Herbal Peel treatment at The Peel Room.

I confirm the above is true and I consent to treatment at The Peel Room *

Your information is kept strictly confidential · The Peel Room