Corrective Treatment Consent Form

Corrective Treatment Consent Form
An corrective treatment may consist of surface cleansing, chemical peels or steam an enzyme application or a application of antibacterial serums, corrective serums and extractions. Treatments take approximately 20 to 45 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for the home care regimen. Implements and equipment used in all this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.
IMPORTANT: PLEASE READ CAREFULLY and initial
Initial here*   I have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way.
Initial here*   I have not had any other chemical peel of any kind, within 14 days of this treatment.
Initial here*   I have not had any facial waxing, within seven days of this treatment.
Initial here*   I have informed the clinic of all health problems of which I am aware, including herpes simplex/cold sores.
Initial here*   I have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane.
Initial here*   I understand that reaching my skin goals is best achieved through a series of recommended treatments and compliance to the home care product program recommended by a your esthetician.
Initial here*   I understand that I will probably experience visible peeling, flaking, discoloration or irritation following this procedure — follow my homecare instructions
carefully.
Initial here   I have not any facial waxing done in the 72 hours.

WARNINGS: PLEASE READ CAREFULLY and initial
Initial here*   Avoid direct sunlight or tanning booths for at least three days following a treatment.
Initial here*   Use of sunblock protection is necessary following all treatments.
Initial here*   Do not pick your skin following a treatment.
Initial here*   Do not use any physical exfoliants until your treatment has finished
RESCHEDULING GUIDELINES AND LATE POLICY: PLEASE READ CAREFULLY and initial
Initial here   A 24-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reserve the right to charge a 50% fee for missed appointments without a 24-hour notice. If you are more than 20 minutes late we cannot guarantee that we will be able to fit your appointment into the schedule and you may not be seen. If we cannot fit you in there will be a 50% fee charged for the missed appointment.
I,   First Name*   Last Name*   , consent to photographs taken of my face to be used for monitoring treatment progress.
I hereby agree to all of the above and agree to have this treatment be performed on me. I further agree to follow all post-treatment care instructions as I am directed.
Name:   First Name*   Last Name*   Date:   Date*