Crystal's Acne Boot Camp Consent

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This must be filled out before your first treatment is scheduled.

First & last name *

Date: *

YYYY

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 orproperly sterilized according to the State Board of Cosmetology regulations.PLEASE READ CAREFULLY & VERIFY: *

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 treatmentsand 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 followingthis procedure if I follow my homecare instructions carefully.

Required

Initial here if you agree that the information checked above is correct. *

WARNINGS: Please read carefully. *

Avoid direct sunlight or tanning booths for at least three days following a treatment.

Use of sunblock protection is necessary following all treatments.

Do not pick your skin following a treatment.

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.

Required

Initial here if you agree that the information checked above is correct. *

RESCHEDULING GUIDELINES AND LATE POLICY: PLEASE READ CAREFULLY: *

A 48-hour rescheduling notice is required. We realize emergencies happen and will be considered, but reservethe right to charge a $50.00 fee for missed appointments without a 24-hour notice. If you are more than 20 minuteslate we cannot guarantee that we will be able to fit your appointment into the schedule and you may not be seen. Ifwe cannot fit you in there will be a $50 fee charged for the missed appointment.

Required

Model Release Form:By signing below, you give Esthetics with Crystal and Face Reality Skincare permission to use your photographs and treatment notes in their publications, advertising and other forms of media. You understand these items will be reused, published, and republished individually or in connection with other material, in any and all media now or hereafter known, including the internet, printing and for any purpose whatsoever, specifically including, promotion, marketing, advertising and trade, without restriction as to alteration. *

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. Initial below *

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