Unique Skin Formulations Inc. Informed Skin
It is important that you understand exactly how to use your products, recognize lifestyle adjustments you need to make to
achieve health – looking skin, and understand all clinical regulations.
PLEASE READ CAREFULLY
All consultations are a pre-paid $55.00 fee and applicable to medical esthetic treatments only (which are non- refundable) if purchased the day of your consultation. If no treatment program is purchased the day of your consultation, the fee is $55.00 for the consultation. For on-line mail order consultations only consultation fee is applicable toward your total home care protocol package cost if purchased the day of your consultation only. If no treatment home care protocol package is purchased the day of your consultation the fee for the consultation is a pre-paid $55.00 non- refundable fee- no exceptions. If the skin develops a true allergy to any specific product the problem product/s will be exchanged within the first 7 days only. – No exceptions- No refunds. Skincare Protocol Packages are for first-time clients only. Product refills are not included in packages. Refills and individual treatments are charged at individual retail and treatment prices. If you are on a Protocol Package follow-up visits are included by appointment only and must be scheduled every 30 days. If you don’t’ follow-up more than six months after your last follow-up visit or clinical treatment, you must start from the beginning with the full consultation process. To avoid misunderstanding, please initial each line. _____ I have read and under stand my homecare protocol and agree to follow directions. _____ I understand that has to adapt to active corrective products. I understand that applying products too often or too thick can cause drying, scaling, darkening or temporary discomfort. I will use caution in the eye, mouth and neck area. _____ I understand temporary blotchiness using a lightener is normal and that dark spots don’t always fade evenly at the same rate as other dark spots. I understand it takes time and effort on my part to achieve an even skin tone. _____ If I use other skin care, cosmetics or hair care products while I am using any product Unique Skin Formulations provides for me I will review them with the staff first. _____ Within the first few weeks I may or may not experience some redness, tightness flaking, itching, drying darkening, blotchiness and mild peeling. This is usually temporary and will subside as my skin adapts to the products if I’m consistent. _____ I will treat the eye and lip area with active ingredients only if the product is formulated for that purpose such as exfoliating ingredients that are in eye creams and lip treatments. When I apply active ingredients to my skin such as AHA, glycolic acid, BPO, salicylic acid, sulfur, BHA or lightening gels I will avoid the eye and lip area, and will always use a sunscreen while I am using any active ingredients. _____ I realize that sun exposure and some medications will make my skin sun sensitive. I agree to wear sunscreen provided by the clinic as directed on a daily basis for any length of time I am exposed to the sun. When continuously exposed to the sun, I will reapply sunscreen often. _____ I understand benzoyl peroxide may bleach hair or fabrics. I will keep all products out of the reach of children or others. _____ I understand that some individuals may develop an allergy to some cosmetic ingredients such as hydroquinone, sunscreen chemicals, benzoyl peroxide, (bpo) or sulfur. Therefore I agree to get patch tested to skin lighteners if recommended by my clinical esthetician. If I develop a true allergy to any of these ingredients the problem Product/s will be exchanged within 7 days only- no exceptions no refunds. For clients who live locally products must be brought back into the clinic, peeling and dryness doesn’t indicate a true allergy. _____ I agree to be consistent in using my products and scheduling follow-up visits. I understand that failure to be consistent may result in dark spots or new breakouts. I understand there is not permanent cure for these conditions but can be controlled with consistent use of products and in- office visits. _____ I understand that stress certain foods- salty, dairy foods, medical conditions – diabetes, high blood pressure, obesity, sun sensitivity, pregnancy, hormonal changes, prescription drugs, drug use including marijuana and stimulants can affect my progress. _____ I understand that skipping clinical visits, not following home care protocols as directed, picking, oily cosmetics, certain hair care products like oil sheens, over scrubbing or friction, will determine the success or failure of my progress. _____ I agree to contact the clinic if there should be any changes in my lifestyle- medication usage, medical history, home care treatments or address or phone number changes. _____ I understand that genetics, (skin conditions that run in families,) hormonal imbalances, stress, certain medications and medical conditions may make some cases difficult to treat. Unique Skin Formulations Inc. doesn’t guarantee, make promises or give time limits regarding any skin treatment offered. _____ I agree to find childcare for all of my scheduled appointments, I understand Unique Skin Formulations Inc. is not equipped to handle small children and infants. _____ I agree (male client) not to shave for 48 hours before my treatments. I agree to avoid active products like skin lighteners, vitamin A glycolic AHA and BPO for 24 to 48 hours after my treatments since my skin may be sensitive from a more aggressive treatment. _____ I agree to get waxing, electrolysis or any other chemical procedure – relaxers hair colors, or perms 48 hours before and after my clinical treatment. _____ I understand that I may experience a flare-up of acne during the first few weeks of treatment since small lesions may be forming underlying the skin and may surface. This is normal and temporary. Visible acne can take up to 90 days to form. _____ I agree to use all products exactly as directed. _____ I understand if I am pregnant or nursing I must not use topical vitamin A creams, gels, drops, hydroquinone, or skin lighteners with hydroquinone in them. _____ I understand that most inflamed conditions like dermatitis, eczema acne etc. can cause hyper pigmentation and scarring and can lightly remain on the skin after the skin has cleared which is due to the condition itself and not the products or treatment. _____ I understand that I may get less than satisfactory results if I partially and not fully apply my recommended home care protocol. _____ I understand that treatments consists of exfoliation procedures, clinical facials along with therapeutic creams, gels, and lotions. I request that Unique Skin Formulations Inc. help improve my skin conditions. I understand I must do my part in order to achieve my skin care goals. _____ I have read and fully understand the above statements. I have been given a copy of this agreement for my reference. I give consent to my treatment program and have read and fully understand the above statements. I agree to follow all directions and clinical procedures. _____ I understand that all prices are subject to change without notice. Please print clearly all information below: Client name ________________________________ Address_________________________________ Phone ___________________________________ Signature __________________________________ Date __________________________________