consent for treatment

Please read, then fill out the form below prior to your first appointment.

A clinical treatment may consist of surface cleansing, exfoliation, application of antibacterial serums, corrective serums, extractions and chemical peels. Treatments take approximately 45-60 minutes to complete and are designed to balance, hydrate, clear acne impactions, improve the texture of skin, wrinkles, pigmentation spots, sun damage, and prepare the skin for your home care regimen. All implements and equipment used in this facility are disposable / sanitized according to the State Board of Cosmetology regulations

All services and products are guaranteed

You can exchange or return a product within 30 days of purchase for any reason. If you get a reaction, rash, or breakout from a product, text or email me immediately!
If you are not completely satisfied with your treatment, let’s schedule another treatment for you as a courtesy.

If you will be more than 15 minutes late, I may have to reschedule your appointment. Please text or call soon as you know you might be late.

Appointment reminders are given as a courtesy. However, you are still ultimately responsible for your appointment time even if you do not get the reminder for some reason.

Please understand it is necessary to give at least 24 hours notice of cancellation of your appointment to avoid the Cancellation Fee, except, of course, in case of illness or emergency. As soon as you know you will be late, call or text Feliz.

Name

First Name

Last Name

Mobile

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Client Consent

I acknowledge that I have not used Accutane during the last three months

I acknowledge that if I am prone to cold sores, fever blisters (Herpes) that I may need a prescription for antiviral medication from my physician prior to having my skin treated. I will need to avoid clinical chemical treatments during breakouts

I acknowledge that for some treatments my skin might experience temporary tightness, redness, or slight swelling which usually dissipates with 1-24 hours depending on skin sensitivity. And if extractions are done, I understand my skin may look worse for 1-7 days until extractions are completely healed

I acknowledge that if I fail to use adequate sun protection (SPF 30), I am more susceptible to sunburn and skin damage

I acknowledge this clinical treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied

I acknowledge that I should avoid the use of exfoliating products, skin cleansing brushes, acids, Retin-A, acne medicines, etc. for 7-14 days following my treatment

I hereby agree to have a skin treatment performed, which can include extractions, microdermabrasion, superficial/ and or deep chemical treatment and agree to follow all pre and post-treatment instructions

I release Feliz Dubois from any and all liability associated with any injuries and/or conditions resulting from skin treatments, microdermabrasion, superficial/ deep chemical treatments, or hair removal procedures

I understand it is necessary to give at least 24 hours notice of cancellation before my appointment time to avoid the cancellation fee, except, of course, in case of illness or emergency. As soon as I know I will be late, I will call or text Feliz.