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 had any other chemical peel of any kind, within 14 days of this treatment.*

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

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

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I have not had any facial waxing, within seven days of this treatment.*

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

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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.*

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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. *

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

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

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Use of sunblock protection is necessary following all treatments.*

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Do not pick your skin following a treatment.*

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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.*

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RESCHEDULING GUIDELINES AND LATE POLICY: PLEASE READ CAREFULLY AND INITIAL

A 24-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reserve the right to charge a $50.00 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.*

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I,*

Full 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 Last

Email*

example@example.com

Date*

Date

City*

State*

Zip*

Signature*