Client Agreement Form
  • Format: (000) 000-0000.

  • Medications

    Please READ the following LIST of medications thoroughly**
  • MEDICATION
  • MEDICAL HISTORY (please check all that apply)
  • Are you under a dermatologist's or other physician's care?

  • Lifestyle Consideration

  • Have you ever had any reaction to any products or anything you have put on your face?      *    If yes, what products? * .

  • Please check any of these you are allergic to:         * 

  • Do you smoke?*
  • Do you use fabric softener or fabric softener sheets in the dryer?
  • Do you swim in a chlorinated pool?
  • Do you work around chemicals, tars, oils, grease or inks?

  • Occupation: Do you work nights?            

  • Are you currently under a lot of stress ?           (common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)

  • Women: Do you use birth control pills, shots or use an IUD?           If so, which do you use?      What brand of pill?      
    Are you pregnant or nursing?            

  • Men: Do you have shaving irritation            
    What type of razor do you use for shaving?

  • Diet - Do you consume the following?

  • Client Agreement Form

    Please initial the agreements below and sign at the bottom

  • * 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

  • * 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.

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

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

  • *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.

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

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

  • *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.

  • *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.)

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

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

  • *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,   *   * hereby agree to all - of the above policies.

  • Pick a Date*   

  • Acne Treatment Consent Form

  • An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, 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!


    * I have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way.
    *   I have not had any other chemical peel of any kind, within 14 days of this treatment.
    *   I have not had any facial waxing, within seven days of this treatment.
    *   I have informed the clinic of all health problems of which I am aware, including herpes simplex/cold sores.
    *   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.
    *   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.
    *   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


    * Avoid direct sunlight or tanning booths for at least three days following a treatment.
    *  Use of sunblock protection is necessary following all treatments
    *  Do not pick your skin following a treatment.
    *  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.

  • I, , authorize and grant DangSkyn to take my photos regarding my experiences with them. I grant DANGSKYN Beauty to use my photos on Facebook, Twitter, Instagram, and other social media platforms. I allow DangSkyn beauty to edit, alter, copy, or distribute the photos for social media advertising and marketing. I agree that the photos belong to DangSkyn, and I understand that I will not receive any monetary compensation.

  • Acknowledgement and Waiver I Herby Agree To Have This Treatment.

    I am aware that products used in facials and homecare may contain tree nuts, sulfur, dairy, and gluten.

    I acknowledge that the estheticians at DangSkyn may use products that contain these ingredients or are manufactured in a plant with these ingredients. 

    I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials. Please inform your esthetican before treatment if severly allergic, as this may make you unable to receive the service. 

    I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form and agree to update DangSkyn as to any changes.

    It is my responsibiliy to disclose all medical, medicinal, and skin history, as DangSkyn will not be responsible to reactions caused by undisclosed medical history.

    I acknowledge the esthetician at DangSkyn do not provide medical advice and

    I accept full responsibility to seek out advice before receiving any services or products from DangSkyn.

    I hereby release, discharge and waive all claims against DangSkyn and each of their employees, and representatives or any person(s) performing services or applying any products at DangSkyn, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates.

    I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.

    I herby 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

  • Pick a Date*   

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