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E SKIN Forté 

Acne Solution + Skincare Clinic 

Acne Treatment Consent Form must be filled  before recieving any acne in-office treatment. 

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, 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 State Board of Cosmetology regulations.

 

ACNE TREATMENT CONSENT FORM

 

***IMPORTANT: PLEASE READ CAREFULLY and initial

I have not been exposed to excessive sun and my skin does not feel sensitive or irritated anyway.

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, including herpes implex/cold sores.

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 a Face Reality certified esthetician.

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

Cutis Skincare products 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.

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.

RESCHEDULING GUIDELINES AND LATE POLICY: PLEASE READ CAREFULLY and initial

A 72-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reserve the right to charge 50% of the full service fee for missed appointments without a 72-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 in there will be a $50 fee charged for the missed appointment.

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.

I Agree

Todays Date: May 18, 2021

 

Please select who will be receiving treatment
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First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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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