Facial Treatment Consent Form

Name of Client *

First Name

Last Name

Name of Parent or Legal Guardian

Applicable if you are a parent or legal guardian submitting this form on behalf of a minor.

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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

Accept

I have not had any other chemical peel of any kind, within 14 days of this treatment. *

Accept

I have not had any facial waxing, within seven days of this treatment. *

Accept

I have informed the clinic of all health problems of which I am aware. *

Accept

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). *

Accept

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 True Simplicity Skin Care esthetician. *

Accept

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. *

Accept

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 *

Accept

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 an SPF 15 is necessary following all treatments. 3. Do not pick your skin following a treatment.

I have read the above warnings and accept.

Photo *

I consent to photographs taken of my face to be used for monitoring treatment progress. I also give True Simplicity permission to use the photographs with the eyes blacked out and no mention of my name in their publications, advertising and other forms of media.:

Yes

No

PRODUCT RETURN GUIDELINES *

True Simplicity Skin Care 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.

I have read the above guidelines and accept.

I, the Client, agree to give at least 24 hours notice of cancellation for appointments. I will PHONE the office at (818) 917-0163 or email True Simplicity Skin Care at karen@truesimplicityskincare.com, at least 24 hours in advance of any appointment I need to miss, cancel or reschedule. *

Accept

I, the Client, understand that reminder call 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. *

Accept

I, the Client, 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. *

Accept

I, the Client, understand that if I am more than 15 minutes late for an appointment and True Simplicity Skin Care cannot fit me in without inconveniencing other clients, it will be considered a missed appointment. *

Accept

I, the Client, authorize True Simplicity Skin Care to charge my credit card on file in order to collect any fees due. I understand True Simplicity Skin Care will send me an email notification prior to charging missed appointment fee(s) to my credit card. *

Accept

I, the Client, have read, understood and agree to abide to the above Appointment Policy Agreement. *

Accept

Today's Date *

MM

DD

YYYY