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TREATMENT CONSENT FORM 

Our treatments 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 TDLR 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 seven days of this treatment.

I have informed the clinic of all health problems of which I am aware.

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 Skin Plus. 

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 three days following a treatment.

Use of sunblock protection of at least a SPF 30 is necessary following all treatments.

Do not pick your skin following a treatment.

PRODUCT RETURN GUIDELINES: PLEASE READ CAREFULLY and initial

Austin Skin Plus prescribes products that 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. All returns must be made within 5 days of purchase for exchange or refund.

RESCHEDULING GUIDELINES: 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 you the cost of your service for missed appointments without a 24-hour notice.

I 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.

Dated: January 15, 2019

First Client Name

First Name*

Last Name*
First Client Date of Birth*
I certify that I am 18 years of age or older
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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.


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