THE_SKN_RN_Acne Treatment Consent Form

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, extract acne impactions, and prepare the skin for the home care routine. 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 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 7 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 any retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane (Isotretinoin.)*
I understand that clear the skin of acne is best achieved through a series of treatments and consistency with the homecare product routine recommended by my Acne Expert.*
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.*
WARNINGS: Please Read Carefully and Initial
Avoid direct sunlight or tanning booths for at least 3 days following a treatment.*
Use of sunblock protection is necessary following all treatments. *
Do not pick your skin following a treatment. *
Face Reality Skincare products are clinical-strength active formulas. Mild tingling sensations are possible with product application but should not be irritating. If you are experiencing stinging and or irritation with any product, stop using the product and contact your Acne Expert for guidance.*
© 2024. Face Reality, LLC. All Rights Reserved. Updated 7/12/23.

RESCHEDULING GUIDELINES AND LATE POLICY: Please Read Carefully and Initial
A 24-hour rescheduling notice is required. We realize emergencies will happen and will be considered, but we reserve the right to charge a $50 fee for missed appointments without 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 into the schedule, there will be a $50 fee charged for the missed appointment.*
I, blanks, 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 performed on my skin. I further agree to follow all post-treatment care instructions as I am directed.
Name
Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zipcode
Signature of Client

Clear
Signature of Esthetician

Clear
Should be Empty:

Acne Treatment Consent Form

WARNINGS: Please Read Carefully and Initial

RESCHEDULING GUIDELINES AND LATE POLICY: Please Read Carefully and Initial