Initials* We must adjust your home care routine every two weeks to keep your progress to clear skin moving forward. If we don’t change how you do your home care often enough, your skin will adapt to the regimen and stop responding (in other words, you won’t get clear). I agree to contact my skincare professional so we can adjust your home care regimen at least every two weeks.

Initials*Each time we strengthen your home care, we run the risk of drying and irritating your skin, so you will need to communicate that to us if that happens. I agree to contact my skincare professional if my skin gets uncomfortably dry and irritated.

Initials* I will not use any other products that have not been approved by my skincare professional while I am on their regimen.

Initials* I will not change the regimen given to me by my skincare professional without notifying or consulting with them first.

Initials* I will not run out of product while working with my skincare professional. When you stop using products (or run out) acne will start forming inside the pores and you will see it about a month later.

Initials* I will not have other skin care treatments while I am being treated by my skincare professional.

Initials* I will inform my skincare professional of any medications/drugs that I start taking while using their regimen.

Initials* I will use my sunscreen every morning, regardless of whether or not I will be going outside. The sunscreen will help to keep your skin moisturized. Without it, your skin will get too dry.

Initials* I will not get sunburned or wind burned while being treated by my skincare professional. (You will not be able to use your active products; and we will not be able to do treatments on you.)

Initials* I will inform my skincare professional if I elect to do any laser treatments or waxing for hair removal.

Initials (For women) - I will inform my skincare professional if I get pregnant.

Initials* MOST IMPORTANTLY: If we are unable to improve the condition of your skin due to factors beyond our control, but within yours, we reserve the right to decline treatments. (That is if you are not following our instructions pertaining to home care, doing your home care, lifestyle issues, etc.)

I, First Name*   Last Name*, hereby agree to all-of the above policies.   

IMPORTANT: PLEASE READ CAREFULLY and initial

Initials * I have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way.

Initials * I have not had any other chemical peel of any kind, within 14 days of this treatment.

Initials*I have informed the clinic of all health problems of which I am aware, including herpes simplex/cold sores.

Initials*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.

Initials* I understand that controlling acne/problem skin is best achieved through a series of recommended treatments and compliance to the home care product program recommended by a Face Reality certified esthetician.

Initials * I understand that controlling acne/problem skin is best achieved through a series of recommended treatments and compliance to the home care product program recommended by a Face Reality certified esthetician.

Initials * I understand that I will probably not experience much visible peeling, flaking, discoloration or irritation following this procedure if I follow my homecare instructions carefully.

WARNINGS: PLEASE READ CAREFULLY and initial

Initials* Avoid direct sunlight or tanning booths for at least three days following a treatment.

Initials* Use of sunblock protection is necessary following all treatments.

Initials* Do not pick your skin following a treatment.

Initials* Face Reality Skin Care products are clinical-strength active formulas designed to treat problem skin conditions. Tingling sensations are normal with product application but should not be painful. If you are experiencing stinging and irritation with any product, stop using the product and call your esthetician for further instruction.

RESCHEDULING GUIDELINES AND LATE POLICY: PLEASE READ CAREFULLY and initial

Initials* A 24-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reserve the right to charge a 30% of the service fee for missed appointments without a 24-hour notice. If you are more than 10 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 30% 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.

First Name*   Last Name*Date*   

 Address*  City*    State*     Zip*   

Signature*  

Model Release Form

By signing below, you give Face Reality Skincare permission to use your photographs and treatment notes in their publications, advertising, and other forms of media. You understand these items will be reused, published, and republished individually or in connection with other material, in any and all media now or hereafter known, including the internet, printing and for any purpose whatsoever, specifically including, promotion, marketing, advertising and trade, without restriction as to alteration.

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Signature*