Client Name

Date of Birth

Email

Address

Phone Number

Please List Any Allergies

When Did You Last Use A Retinol/Retina Product?

I agree to the following (Please check if you agree):
I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, dermabrasion, dermaplaning, extractions, microneedling (if scheduled) high frequency, ultrasonic, LED Light Therapy and other treatment modalities as necessary.
I understand that this is a cosmetic treatment and that no medical claims are expressed or implied.
I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol instructions that I'm given.
I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual.
I understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness or tightness, and that the next few days there could be redness, brown/purple discoloration indicated peeling, and other skincare conditions related to the healing process.
I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment.
I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sunblock protection with a minimum SPF 30 is mandatory.
I understand that the appropriate etiquette for a facial is to arrive on time, not be rude and be on my phone during my treatment, and to give a 24 hour notice of canceling any appointment or I will be charged a $35 No Show Fee.