Treatment Consent Form

Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for
how long you used them.

Please list the following Information for your Primary Care Physician

I have read and understood this Form in it's entirity. Any questions or concerns I may have, have already been addressed with my Esthetician. I understand that receiving a treatment means following correct Home Care instructions/ products. Redness, inflammation, dryness, and purging may occur. I consent to following specific Post- care instructions. Including but not limited to: SPF, no sun for up to a week, no actives or exfoliants up to a week, no new products without consulting Esthetician. I agree to all effects that come with a treatment. I consent to receiving Treatment.