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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.


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, 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. 

Date: July 14, 2025 

First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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Participant's 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:*
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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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
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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