Acne Treatment Consent Form - Glo

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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, 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.
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, including herpes simplex/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
______Face Reality Skin Care 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 24-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reserve the right
to charge a $50.00 fee 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.
Name: _________________________________________________________________________ Date:_________________
Address: _____________________________________________ City: _____________________State: ____ Zip: _________
Signature of Client: ____________________________________________________________
Signature of Esthetician: ________________________________________________________

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