Treatment Consent Form

A True Simplicity Skin Care 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 True Simplicity Skin Care procedures are disposable or properly sterilized according to the State Board of Cosmetology regulations.

By completing this form and clicking the "I CONSENT" button below, you agree to the following:

1) You are submitting a legal document to True Simplicity Skin Care.

2) If you are the parent or legal guardian submitting this form on behalf of a minor, you agree to attend the minor's first appointment.

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


Name of Client *
Name of Client
Name of Parent or Legal Guardian
Name of Parent or Legal Guardian
Applicable if you are a parent or legal guardian submitting this form on behalf of a minor.
Client's Date of Birth *
Client's Date of Birth
Address *
Address
Consent to Terms of Service
By checking each of the boxes below, you are indicating that you are in compliance with, or consenting to, the term of service.
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 True Simplicity Skin Care 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. *
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. *
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.
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.
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, 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. *
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. *
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. *
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. *
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. *
I, the Client, have read, understood and agree to abide to the above Appointment Policy Agreement. *
Today's Date *
Today's Date
Please type your full name in all CAPS to indicate your lawful signature.