Acne Client Consultation

  • Acne Client Questionnaire

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • What's the best way to contact you? (Select all that apply)
  • Format: (000) 000-0000.
  • Do we have permission to show your non-identifying photos for social media purposes?
  • How did you hear about Estie Co.?

  • Medical History & Intake

  • Rows
  • Rows
  • Format: (000) 000-0000.
  • Are you under a dermatologist's or other physician's care?

  • Lifestyle Considerations

  • Have you ever had any reaction to any products or anything you have put on your face?
  • Please check any of these you are allergic to:
  • Do you smoke?
  • Are you prone to cold sores? (Treatment cannot be completed if the client has an active cold sore. Client must wait until the cold sore is completely healed before scheduling a treatment.)
  • 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?
  • Do you work nights?
  • How would you describe your stress level?
  • Are you Vegan?
  • Women: Do you use birth control pills, shots, or use and IUD?
  • Men: Do you have shaving irritation?
  • Rows
  • Rows
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  • I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company (Estie Co. LLC)  and/or skin care professional from liability.

  • Date
     / /

  • 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 windburned 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.)

  • 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 45 minutes to an hour 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 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.

       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 my 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 3 days after treatment.
    Use of sunblock protection is necessary following all treatments.
     Do not pick your skin following a treatment.
     The products picked for you by your esthetician 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, Late Policy, and Illness 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 15 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 to the cc on file for the missed appointment. Please do not come to your appointment if you are feeling sick AT ALL. Reschedule your appointment for a later date. This keeps everyone safe and allows your esthetician to continue working. There will be no exceptions for this, if you are sick, you will be sent home and charged 90% of the service.

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