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Acne Treatment Consent Form

A Face Reality Acne & Skin Care Clinic acne treatment may consist of surface cleansing, steam, exfoliation, application of antibacterial serums, corrective serums, extractions and masks. Treatments take approximately 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 Face Reality Acne & Skin Care Clinic procedures are disposable or properly sterilized according to the State Board of Cosmetology regulations.

* ALL FIELDS ARE REQUIRED


IMPORTANT: PLEASE READ CAREFULLY and INITIAL WHERE INDICATED.

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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 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 Acne & Skin Care Clinic 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

1. Avoid direct sunlight or tanning booths for at least three days following a treatment
2. Use of sunblock protection of at least a SPF 15 is necessary following all treatments.
3. Do not pick your skin following a treatment

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PRODUCT RETURN GUIDELINES

Face Reality Acne & Skin Care Clinic products are clinical-strength active formulas designed to treat problem skin conditions. Stimulating 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 the Clinic for further instruction. All returns must be made within 15 days of purchase for exchange or refund.

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APPOINTMENT POLICY AGREEMENT

Failure to cancel or reschedule appointments appropriately, not only affects the estheticians and staff, but also other clients who may have been in need of that appointment time. Please be respectful of your time and ours.

I, the Client:

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Agree to Give At Least 24 Hours Notice of Cancellation for appointments. I will PHONE the office at 510.351.1842 or email Face Reality at info@facerealityacneclinic, at least 24 hours in advance of any appointment I need to miss, cancel or reschedule.

Understand that reminder calls services may be provided as a courtesy, are not guaranteed; and should I not receive one, I am still responsible for my appointments and any consequences associated with failing to keep or be on time for appointments.

Understand that any appointment missed, canceled, or rescheduled without 24 hours notice, incurs a $50 missed appointment fee which I agree to pay. If the session was part of a pre-pay program, that session will be lost, without reimbursement.

Understand that if I am more than 15 minutes late for an appointment and Face Reality cannot fit me in without inconveniencing other clients, there will be a $50 missed appointment fee that I agree to pay. If the session was part of a pre-pay program, that session may be lost without reimbursement.

I, THE CLIENT, authorize Face Reality, Inc., to charge my credit card on file in order to collect any fees due. I understand Face Reality, Inc., will send me an email notification prior to charging missed appointment fee(s) to my credit card.

I, THE CLIENT, have read, understood and agree to abide to the above agreement.

 

I, (First and last name) 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.

PLEASE TYPE YOUR FULL NAME IN ALL-CAPS TO INDICATE YOUR SIGNATURE: (if under 18, please have parent/guardian sign)

 

Name:

E-mail:

Date:

(mm/dd/yyyy)

Address

City

State

Zip

 

By clicking the submit button below you agree to the following:

  1. You are submitting a legal document to Face Reality Skincare Clinic.

  2. All information on this form is accurate to the best of your knowledge.