Teen Client Compliance Form

Today's Date: February 27, 2021



The team of Envision Acne & Skin Care Center has been working with clients at all ages to help clear up their acne. It is our experience when it comes to treating clients under the age of 18 the outcome of their treatments varies and can be more difficult than treating adults.


If you are considering to sign up your teenager for our Acne Free Skin Program we highly recommend reading all the information on our website carefully so you have a better understanding of what our program is about. When it comes to treating teenagers there is a certain compliance level required in order to get the full benefits of our program.


Often we see parents who are desperate to clear up their teen's acne but the teen is not as interested or not willing to make the necessary changes required to clear up his or her skin. If the teen is not 100% compliant with the home care and not willing to make the necessary dietary and lifestyle changes required he or she will not be able to achieve the results you are looking for.


You also have to take it under consideration that teenagers go through many hormonal changes during puberty. These hormones have asignificant effect on their skin and could be one of the main cause fo their acne.


Examples of non-compliance:

  • Not following the proper use of home care products.
  • Skipping the use of home care products.
  • Doesn't have the time to do the home care routine (school starts early or getting home late from practice).
  • School and exams are extremely stressful and cause extra stress and anxiety.
  • Eating fast food with friends after school.
  • Eating sugary foods and drinking sodas.
  • Not showering right after a workout
  • Not willing to change her make up.


With all that said we had many teen clients who achieved great results in our program because they were committed. The others only got partially clear because this program just wasn't the right choice for them.

If you would like to book an appointment for your teenager we require both of you to be present at the first consultation so together we can discuss if this is a right program for your teenager.


Some things to take into consideration:

  • The success of the program will highly depend on the commitment level and maturity of the teenager.
  • During the clearing process, the client may experience dry, flaky skin and may develop occasional break-outs.
  • Certain dietary and lifestyle changes will be necessary to clear up acne prone skin.
  • During in-office treatments, clients are receiving extractions which may cause temporary redness in the skin.
  • In order to achieve completely clear skin, you have to give up the daily use of all skincare and makeup products with pore clogging ingredients.


I agree that I read and understand the level of commitment required to successfully complete the Acne Free Skin Program.

I Agree

Please select who will be participating...
First Participant's Name

First Name*

Last Name*

First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Parent or Guardian's Email Address


Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

One or more problems exist. Please scroll up.

Powered by  Smartwaiver - TRY IT FREE!