CLIENT COMPLIANCE, CLIENT CONSENT, and CLINIC POLICY thank you for filling out the new client intake form! now please take a few minutes to complete skinSALVATION’s client compliance, consent, and clinic policy form. please check each statement to acknowledge that you have read it. you will be asked to sign at the end of each section. upon completion, we will email you a copy for your records. Step 1 of 3 33% Name* First Last Email* Today's Date* Date Format: MM slash DD slash YYYY are you (the client) under 18?*yesnoclients under 18 are required to be aware of and consent to additional conditions.TEEN COMPLIANCEplease indicate that understand the unique challenges faced by teen clients outlined below.* the clarity rates for teens are simply not as high as for those who are over 18. there are many factors that contribute to this, and none of them are under anyone’s control. * therefore, we cannot guarantee the 90-95% success rate we offer our adult clients. teen acne varies drastically, case-by-case, and while some teen clients attain clarity, others may not even get to 25 - 50% clarity. * teen clients, not just their parent(s), need to be fully invested in the program in order to see any positive results. the skinSALVATION method includes extractions (which can be very painful) and downtime after treatments (that can include peeling skin, redness and scabs for up to a week). the sS method also requires significant lifestyle changes: dietary, stress management, product changes, and school and scheduling management.* complying with the skinSALVATION method is the most important factor in improving your chances of the program working for you. teen clients must do their part for the lifestyle changes, especially with dietary changes and stress management, as well as doing the homecare regimen twice a day and coming in for treatments as recommended. * there is no guarantee on the success of the teen program; under no circumstances will no refunds for treatments or products will be given. PART ONE: CLIENT COMPLIANCEthese are guidelines that we are clearly communicating to you so that you know what is required on your part as a client in order to reach the full potential of the skinSALVATION acne clearing program. please read carefully and know that not complying to every single component can and will hinder your success!in order to get the best and safest results, i understand that i will need to comply to the following:* i am aware that after corrective acne treatments, my skin may temporarily become sensitive, irritated, red, bumpy, dry, flaky, or in very rare cases, get hyperpigmented. i understand that these are expected side-effects after very thorough extractions and chemical peels. i will allow a healing time of 2 days to 6 weeks for the true results of the treatments to come through. * to come in for follow up treatments as advised. typically, clients come in every two to three weeks until their acne is under control, which on average takes 3 months, or 6 treatments. * to use my acne safe corrective skincare regimen products as directed and to refill them before i run out. the regimen includes icing, both day and night for the best results. * to use only skinSALVATION tested and approved products. using products that have not been tested and/or approved by sS or have comedogenic ingredients in them may cause more acne, and delay the clearing process. * to disclose that i am using (or have within the last 6 months) isotretinoin, a.k.a. accutane. i understand that this drug, combined with extraction treatments and some sS home care products may have negative and damaging effects on my skin - some of which may be permanent, and irreversible. if i choose to use this prescription and continue treatments i understand that this is against the direct recommendation of sS, and that i must provide a written doctors note that allows me to receive extractions and light certain exfoliant products/chemical peels while under (and within 6 months' use of) the prescribed drug. i also understand that the limitations of such treatments and products are to be administered under the discretion of skinSALVATION and may be limited in order to keep me safe. * to refrain from the use of any topical prescriptions for acne. i understand that these products, combined with treatment and sS home care products may have negative and damaging effects on my skin - some of which may be permanent, and irreversible. if i choose to use topical prescriptions and continue treatments i understand that this is against the direct recommendation of sS, and that i must provide a written doctors note that allows me to receive extractions and light chemical peels while under the prescribed drug. * to wear sunscreen everyday and be conservative with sun exposure. sun exposure can disrupt the skin's healing process, and cause hyperpigmentation and/or damaged skin. * to never pick! picking at your skin is just as bad as not doing your skincare regimen. it can be very disruptive to the clearing process, and can cause permanent skin damage. * to keep open communication with sS so that we can work together. this is especially important if you experience stinging, burning, irritation, or dryness with your homecare regimen. * i understand that repeatedly not complying may be grounds for dismissal as a skinSALVATION client. * i understand that the employees of skinSALVATION are not doctors who diagnose or prescribe, nor do we cure acne. the sS method empowers its clients to live an acne-safe lifestyle, and to support the purging process, offers corrective skincare treatments, and dispenses acne-safe corrective skincare products. * i understand that in the rare case that my skin does not show progress by the sixth treatment, this may be an indicator that there is a larger, underlying issue. sS may recommend seeing a natural whole-body practitioner to help identify and address the bigger issue, of which acne is only a side effect.i understand that sS will let me know as soon as they are able to detect if this may be the case, and if so, that the sS method alone will not control my acne. . please sign, indicating your understanding of the client compliance policy.* PART TWO: CLIENT CONSENT* i understand that after corrective acne treatments, my skin may temporarily become sensitive, irritated, red, inflamed, bumpy, dry, flaky, or hyperpigmented -- especially after very thorough extractions and chemical peels. i will allow for a healing time of 2 days to 6 weeks, for the the true results of the treatment to come through. * i will explicitly comply to the directions given to me on post-treatment skincare, to avoid healing complications and scarring. * i understand that photographs will be taken for documentation purposes. all photos will be kept strictly confidential unless i grant written permission for their use. * i confirm that all of my answers on the new client intake form are current and true. i have not withheld any relevant information which may introduce complications when combined with the skinSALVATION method. * i understand that by signing this waiver, i waive and release all rights and claims to pursue damages against skinSALVATION acne clinic, part of skinSALVATION inc., and/or its employees should any adverse and even permanent side effects occur. please sign, indicating your consent.* PART THREE: CLINIC POLICIESCANCELATIONS, RESCHEDULING, and REFUNDS* CONSULTS require a full, seven days' notice to cancel or reschedule without penalty.if you cancel or reschedule within the 7-day window, you will be charged the full cost of the appointment. however, if you are rescheduling the appointment, and we are able to book clients during that time, we will only charge you for the time that remains unbooked as a result of the late cancellation. any remaining balance will be transferred as a credit to your account for future use with skinSALVATION. * FOLLOW-UP APPOINTMENTS require 48 hours notice to cancel or reschedule.if you cancel or reschedule within 48 hours, or no-show for the appointment, you will be charged the full cost of the appointment. POPZIT appointments: i understand i will be charged $10 for every missed popzit appointment, whether it is a no-show or i've arrived too late to be serviced for it * i agree to keep a credit card on file with sS at all times and authorize skinSALVATION to charge it, should i ever cancel, reschedule or no-show for an appointment inside the late cancellation/reschedule window.the card i choose to keep on file will be current and valid, and will be updated as needed. * i understand and agree to skinSALVATION's 48-hour rescheduling and cancellation policy. by checking this box, i agree and authorize skinSALVATION to charge my card on file for any and all appointment modifications made within the 48-hour period prior to my scheduled appointment time. * i understand that using the online scheduler is the most effective and guaranteed way to manage my appointments, and will use this as my primary method of doing so. when using the online scheduler, i understand the scheduling system will send me an email confirmation of any appointment changes i've made to confirm my modifications.emails, voicemails and phone calls to the clinic may not be answered until the next business day, resulting in a late cancellation/rescheduling charge. * if i choose to opt-out of email reminders & notifications, i understand will not get ANY email correspondence from the mindbody scheduling/sales system. this includes appointment booking, cancellation confirmations, appointment reminders, and receipts. i understand that in the event i miss an appointment and i have opted out of getting appointment reminders, i authorize skinSALVATION to charge my card on file for the appointment missed. * CALLING IN SICK to an appointmenti will not come into the clinic sick or within the first 3 days of getting sick, so as to avoid spreading the illness to our staff and other clients. as soon as i start to feel sick, i will let the skinSALVATION reception team know, so that i can be put on stand-by for my appointment slot, and sS can attempt to book my appointment slot with another client, to avoid a cancellation/rescheduling charge to my account. i understand that in the event i come in for a service while still contagious, skinSALVATION has the right to deny me treatment, and charge my card on file in full for the treatment cost. * i understand that there are absolutely no refunds for products or treatments (either already rendered, or paid in advance), whether the desired results of the treatment/products are achieved or not. products may be exchanged for store credit only in cases of allergic or adverse reaction, at the discretion of skinSALVATION inc. please sign, indicating you consent to all clinic policies.*
