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Client Agreement Form

Please thoroughly read the agreements below, initial each, and sign at the bottom.

*Acne treatments at Atlanta Acne Specialists, LLC may consist of surface cleansing, mild chemical peels or enzyme exfoliation, extractions, application of antibacterial serums &/or corrective serums, and application of an SPF. Treatments take approximately 30 to 60 minutes to complete and are designed to balance, hydrate, & clear acne impactions. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.

 

-Atlanta Acne Specialists products are clinical-strength, active formulas designed to reduce acne conditions. Tingling sensations are normal with product application, but it should not be painful. If I experience stinging/burning with any product, I will stop using the product and contact my Acne Specialist immediately.

-I have not been exposed to excessive sun and I have let the office know if my skin currently feels sensitive or irritated in any way.

-I will use the products I have received from my Acne Specialist exclusively while I am on the program and I will use the products as directed.

-I will use my sunscreen every day of the year with no exceptions.

-I will repurchase products before I run out, while working with Atlanta Acne Specialists. *When you stop using products acne will start forming inside the pores and you will see it about a month later.

-I have informed the office of any use of oral or topical medications I may be using. (including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane) 

-I will inform my Acne Specialist of any medications/drugs that I start taking while on their regimen.

-I will inform my Acne Specialist if I elect to do any laser treatments or waxing for hair removal on my acne affected areas.

-I will not have any facial waxing within seven days (before or after) of this treatment.

-I will not have any other facial treatment or chemical peel of any kind, while working with Atlanta Acne Specialists.

-I will avoid tanning (outdoors or in tanning booths) while under the care of Atlanta Acne Specialists.

-I have informed the office of all health problems of which I am aware. (including herpes simplex/cold sores) 

-I will inform my Acne Specialist if I am pregnant or plan to become pregnant.

-I will not pick my skin while using Atlanta Acne Specialists' products.

-I understand that I will probably not experience much visible peeling, flaking, discoloration or irritation after the treatments if I follow my homecare instructions carefully, as directed.

-I recognize that my home-care routine will need to be adjusted on a regular basis to keep progressing toward clear skin. And I agree to check the support page every two weeks and/or I will make sure to check my email regularly to remain up to date with the changes recommended by the Acne Specialist. 

 

-Each time we strengthen your home care, we run the risk of drying and irritating your skin. I agree to communicate that to my Acne Specialist if that happens.

 

 

-I understand that although emergencies happen and will be considered, Atlanta Acne Specialists reserve the right to charge a $50.00 fee for missed appointments without a 24-hour notice.

-I understand that if I am more than 15 minutes late for an appointment*, Atlanta Acne Specialists does not guarantee I will be seen. If my Acne Specialist cannot fit me into the appointment schedule, I will be charged a $50 missed appointment fee.

*Your appointment starts at your appointment time, not when you arrive.

 

 

 

 

 

 

*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.)

--Products may be returned within 30 days for a full refund, provided they have not been opened and/or used. If products have been opened or used, it is mandatory to speak with an esthetician to obtain authorization to return that product.

 

I Agree

December 13, 2018

 

*We at Atlanta Acne Specialists want you to have a great experience at our office. You deserve the best of care and we are here to provide thorough treatments, guidance and expert advice. Your appointments will be one-on-one with your acne specialist and we look forward to getting you started on your path to clear skin!

Please select who will be participating...
AdultMinor
Continue
First Client's Name

First Name*

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

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Model Release Form
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.*
Yes
No
I give permission to Atlanta Acne Specialists to use my photograph for the purpose of promoting their products and services. I understand that there is no implied or explicit renumeration that I expect to receive.*
Yes
No
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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