Detox Facial – Comprehensive Consent and Concern Form

First Name

Last Name

Gender

Address

Street Address

City

Postal Code

Phone *

Email *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical care or taking any prescriptions?

Yes

No

If yes, please specify:

Have you had Fillers, Botox, Chemical Peels, or Laser treatments recently?

Yes

No

If yes, please describe:

Skin Priorities & Lifestyle

What are your primary skin concerns today? (Select all that apply)

Have you received a professional deep-cleansing facial before?

Yes

No

If yes, please specify details of the procedure and your experience:

Do you wear SPF daily?

Yes

No

Do you use any active skincare ingredients (acids, retinoids, vitamin C)?

Yes

No

Treatment Overview & Expectations

A Detox Facial focuses on deep-pore cleansing, enzymatic exfoliation, and debris extraction.
Some redness is common immediately following extraction or steam.
For optimal detoxification, we recommend staying hydrated and following the prescribed home care regimen.

Acknowledgments & Safety Protocols

Please initial each point for the Detox Facial Treatment:

I understand that results vary based on individual skin type and lifestyle factors.

I am aware that a "purging" period (minor breakouts) may occur as toxins are drawn to the surface.

I understand that manual extractions may cause temporary sensitivity or localized redness.

I agree to follow the 24-hour aftercare advice, including avoiding sun exposure and heavy makeup.

I confirm that all health information provided is truthful and complete.

I permit the taking of "Before & After" photos for my confidential clinical file.

Official Declaration & Consent

Please verify the following for the Detox Facial Treatment:

I confirm all provided data is accurate.

I fully understand the detox facial process, its benefits, and potential side effects.

My practitioner has addressed all my concerns.

I authorize Idens Laser Clinic to perform this treatment.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature

Clear

Date *

Practitioner Signature

Clear

Deposit & Risk Acknowledgment Policy

Non-Refundable Booking Policy

I acknowledge that all deposits for facial treatments are non-refundable. This policy remains in effect regardless of cancellation, late arrival, or rescheduling.

Waiver of Liability

I recognize that skin treatments involve certain risks. I have been briefed on the procedure and potential outcomes. I assume full responsibility for the results and release the clinic and its staff from liability regarding unforeseen skin reactions or variations in results.

Agreement

By signing, I verify that I have read the above policies, understand the non-refundable nature of my deposit, and accept all risks associated with the treatment.

Patient name

Patient Signature

Clear

Date

I agree to terms & conditions provided by the company.

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