Treatment Consent: I voluntarily consent to receive esthetic services provided by Double Cleanse Skin in Goodyear, Arizona. I understand that these services are performed by a licensed esthetician and are not a substitute for medical advice, diagnosis, or treatment. I agree to inform my esthetician of any changes to my health or medications prior to each visit.

Accuracy of Information: I confirm that the information I have provided on this intake form is accurate and complete to the best of my knowledge. I understand that withholding or misrepresenting health information may affect the safety and outcome of my treatment. I agree to update my intake information if my health status changes.

Possible Reactions: I acknowledge that esthetic treatments may occasionally result in temporary reactions including, but not limited to, redness, dryness, mild irritation, breakouts, or heightened sensitivity. I understand that Double Cleanse Skin will take every precaution to minimize adverse reactions, and I agree to inform my esthetician immediately of any discomfort during treatment.

Release of Liability: I release Double Cleanse Skin and its owner, employees, and agents from any and all liability for adverse reactions, injuries, or outcomes that result from undisclosed health conditions, medications, or allergies, or from my failure to follow pre- and post-care instructions provided by my esthetician.

Pre & Post-Care: I agree to follow all pre- and post-care instructions provided by my esthetician to achieve the best possible results and reduce the risk of complications.

Cancellation Policy: I understand that a minimum of 24 hours notice is required for cancellations or rescheduling. Late cancellations or no-shows may be subject to a cancellation fee.

Understanding of Procedure: I understand that extractions involve the manual removal of blackheads, whiteheads, and clogged pores. I acknowledge that this process may cause temporary redness, sensitivity, minor swelling, or spotting at the extraction site, which typically resolves within 24 to 72 hours.

Risks and Acknowledgment: I understand that there is a risk of post-extraction hyperpigmentation, particularly for deeper skin tones or skin with active inflammation. I acknowledge that my esthetician will only perform extractions on comedones that are safe to extract and will never force extractions that could cause damage to the skin tissue.

Active Conditions: I confirm that I do not have any active cystic acne, open wounds, cold sores, or contagious skin conditions in the treatment area. I understand that extractions will not be performed over active cystic nodules, as this can cause further inflammation and scarring.

Post-Care Agreement: I agree to follow all post-extraction care instructions including avoiding touching the face, wearing SPF daily, and avoiding active exfoliants for a minimum of 48 hours following the service.

Right to Decline: I understand that my esthetician reserves the right to decline or discontinue extractions at any time based on professional judgment for my skin safety.

Scope of Consent: This consent covers the use of chemical exfoliants, enzyme treatments, AHA/BHA acids, professional-grade peels, and any other active ingredient treatments that may be incorporated into my facial service at Double Cleanse Skin.

Expected Responses: I understand that chemical exfoliation and active treatments may cause temporary tingling, warmth, redness, tightness, and visible peeling or flaking in the days following treatment. These are normal and expected responses that indicate cellular turnover is occurring.

Contraindication Disclosure: I confirm that I have accurately disclosed all current medications, topical prescriptions, and supplement use. I understand that certain medications including isotretinoin (Accutane), topical retinoids, antibiotics, and blood thinners may increase sensitivity and contraindicate certain treatments. I agree that if I have used prescription retinoids within the last 5 to 7 days, I will disclose this prior to treatment.

Sun Sensitivity: I understand that chemical exfoliation increases photosensitivity. I agree to wear broad-spectrum SPF 30 or higher daily following my treatment and to avoid prolonged sun exposure for a minimum of 7 days post-treatment. I acknowledge that living in Arizona, consistent SPF use is non-negotiable for protecting my results.

Post-Treatment Restrictions: I agree not to use any active exfoliants at home, including retinols, AHAs, BHAs, or physical scrubs, for a minimum of 5 to 7 days following a chemical exfoliation treatment, or as specifically instructed by my esthetician.

Results Disclaimer: I understand that results from active treatments vary based on individual skin type, compliance with post-care, lifestyle, and consistency of treatment. I acknowledge that a single treatment may not produce dramatic results and that a series is typically recommended for optimal outcomes.

Collection of Information: I understand that Double Cleanse Skin collects personal, health, and skin-related information for the sole purpose of providing safe and personalized esthetic services. My information will be stored securely and will never be sold, shared, or distributed to third parties.

Health Information Privacy: I understand that all health and medical information I provide is treated as confidential. This information is accessible only to the licensed esthetician providing my services and is used exclusively for treatment planning and safety purposes.

Communications: I understand that by providing my phone number and email address, I may receive appointment reminders, post-care follow-up messages, and service-related communications from Double Cleanse Skin. I acknowledge that I can opt out of promotional communications at any time by contacting the studio directly.

Record Retention: I understand that my client intake form and treatment notes may be retained for a period consistent with standard business and legal record-keeping practices. I have the right to request access to or deletion of my information at any time by contacting Double Cleanse Skin directly.

Right to Update: I understand it is my responsibility to inform Double Cleanse Skin of any changes to my health, medications, or contact information prior to future appointments so that my records remain accurate and my treatments remain safe.

Deposit Policy: A non-refundable deposit is required to secure all appointments. My booking system will send a deposit reminder 72 hours prior to your appointment. The deposit must be completed at that time in order to keep your reservation active. Deposits are applied toward your service total on the day of your appointment and are non-transferable and non-refundable, except when proper notice is given as outlined below. By booking your appointment, you authorize Double Cleanse Skin LLC to charge the card on file for this deposit and for any fees associated with late cancellations or no-shows.

Cancellation & No-Show Policy: We require a minimum of 48 hours notice to cancel or reschedule an appointment. This allows us to offer your time slot to another client.

Late Cancellations: Cancellations made less than 48 hours in advance will result in forfeiture of your deposit.

Same-Day Cancellations & No-Shows: Same-day cancellations and no-shows will be charged 100% of the scheduled service total to the card on file.

Late Arrivals: A 10-minute grace period is allowed for late arrivals. After 10 minutes, the appointment may be considered a no-show and fees will apply.

Card Authorization: By booking, you acknowledge and agree that your card may be charged in accordance with this policy. These charges are authorized and not eligible for dispute or chargeback, as your consent and acknowledgment are recorded at the time of booking. If the card on file is unavailable to be charged at a missed or no-show appointment, the client must pay in full at the time of the next booking and will be unable to make future appointments without contacting Double Cleanse Skin LLC directly with payment of service.

Exceptions: We understand that emergencies happen. One courtesy exception may be extended at Double Cleanse Skin's discretion.

Authorization: I understand and agree to the deposit, cancellation, and no-show policy set by Double Cleanse Skin LLC. I authorize Double Cleanse Skin LLC to charge my stored card for deposits, late cancellations, and no-show fees as described. I understand these fees are non-refundable and may not be disputed once charged.

I understand that the SWiCH™ Dermal Rejuvenation treatment is intended to improve the condition and appearance of my skin. I understand that the product has been thoroughly studied and clinical trials have been performed on a variety of skin types, and that clinical results may vary according to my own skin type and conditions.

I agree to be truthful about my physical conditions, pregnancy, medications I may be taking, and my current skin care regimen. I am aware that my lifestyle, which includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption, and/or recreational use of controlled substances, will affect and may diminish the effectiveness of the SWiCH™ treatment.

I am aware that I may experience possible short-term effects including reddening, mild stinging, scabbing, feeling of tightness, and acne-like eruptions in the days following treatment.

I understand there is a possibility of rare side effects. Should I experience an extreme response to this treatment, I have been provided contact information for immediate response and remedy.

I understand the cost of the treatment and fee structure has been explained to me. I understand that I will be provided products following the treatment and that written instructions for their use have been explained to me. Compliance with these products is required for demonstrated results.

I confirm that NONE of the following conditions currently apply to me. If any of these apply, I agree to contact my esthetician immediately by text at (623) 299-6361 prior to my appointment:

In the event of any questions or concerns, I will consult my skin care professional immediately. I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration. I will hold the skin care professional and staff harmless from any liability that may result from this treatment. I certify that I have read and fully understand the above and that this constitutes full disclosure superseding any previous verbal or written disclosures.

Purpose: This form provides information and obtains consent for the topical application of a compounded anesthetic ointment containing 23% Lidocaine and 7% Tetracaine prior to treatment (such as microneedling). This topical anesthetic helps minimize discomfort during the procedure.

How It Works: The ointment temporarily numbs the skin by blocking nerve signals. It is applied topically and left on for approximately 15 to 30 minutes prior to treatment. The numbing effect may last 1 to 2 hours.

Possible Side Effects: While adverse reactions are rare when used appropriately, potential side effects may include temporary redness, swelling, or blanching at the application site; mild burning or stinging; allergic reaction (itching, rash, hives, or difficulty breathing — seek immediate medical attention if this occurs); local irritation or sensitivity; and systemic toxicity (very rare) from overuse or absorption through broken skin.

Do not use if you have a known allergy to Lidocaine, Tetracaine, Benzocaine, or other "-caine" medications, or if you have a history of cardiac, liver, or seizure disorders without medical clearance.

Precautions: Only licensed professionals will apply the topical anesthetic. The cream will not be applied to open wounds or infected skin. You may feel temporary numbness, tingling, or loss of sensation in the treated area. Avoid touching or rubbing the area until sensation returns.

Consent: I have read and understood the information above. I have disclosed all medical conditions, allergies, and medications to my provider. I understand the purpose, risks, and possible side effects of topical anesthetic use. I give permission for Double Cleanse Skin LLC and its licensed provider to apply the 23% Lidocaine / 7% Tetracaine topical anesthetic prior to my procedure. I release Double Cleanse Skin LLC, its owner, and staff from any liability related to adverse reactions that may result from the use of topical anesthetic, except in cases of proven negligence.

I give permission to Ashley Moran at Double Cleanse Skin LLC to perform dermaplaning treatment. I agree to be truthful about my physical conditions, pregnancy, medications I may be taking, and my current skin care regimen. I am aware that my lifestyle, which includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption, and/or recreational use of controlled substances, may affect the outcome of the treatment.

I have disclosed to my skin care professional any surgical procedures, laser treatments, or facial procedures I have had or intend to have in the future.

I have not received Botox or fillers within 1 week of this appointment. I have not used any form of Vitamin A within the past 5 days and will not use Vitamin A for 5 days after the service. I have not had any recent chemotherapy or radiation treatments in the past year. I have not recently waxed or used a depilatory on the area being treated today.

I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters or cold sores. I have not had any peel treatment within 14 days of treatment. I understand I cannot have another treatment within 14 days, whether at this location or any other.

I agree to refrain from excessive sun exposure or tanning bed use while undergoing treatment and during the 14 days following. I understand that SPF is mandatory following treatment and that Circadia Light Day Broad Spectrum Sunscreen will be used after the treatment.

I understand the purpose of this procedure is to exfoliate the outer surface of my skin. Benefits include lessening of pigmentation, reduction in appearance of fine lines and wrinkles, and control of certain conditions such as acne. My expectations are realistic and I understand results are not guaranteed. More than one application may be necessary for maximum results.

I confirm that NONE of the following conditions currently apply to me:

I understand that Ashley Moran, owner and operator of Double Cleanse Skin LLC, is a certified and trained professional in microneedling and will use a combination of various topical injectables in conjunction with microneedling to help achieve improvements to my skin. This treatment is designed to create a controlled wound to deeper layers of the skin while leaving healthy tissue surrounding the injury in order to enhance collagen production with minimal downtime.

I am not allergic to any medications and am not using prescription Retin-A or Accutane. I understand and agree to cooperate with Ashley Moran in this process, which may involve multiple treatments and downtime ranging from one week to 3 months depending on how my skin heals.

I do not have a history of keloids or hypertrophic (raised) scars. I do not have a history of hyperpigmentation when my skin is injured. I have been counseled regarding the risks and benefits of this technique, including the possibility of no improvement or increased scar formation, and I agree to proceed.

I agree to follow the recommended skincare before, after, and in between treatments as recommended for my skin type. I know that I may experience redness, tingling, superficial abrasions, and temporary scab formation and flaking. I will advise Ashley Moran promptly of any concerns or adverse effects and will seek medical attention as recommended.

I am 18 years of age or older and have informed Ashley Moran of any physical or psychiatric health problems that would prevent me from having this procedure. I understand that temporary redness, swelling, bruising, and discomfort occur from this procedure. Possible complications include, but are not limited to, risk of infection, allergy or sensitivity to local anesthetics, and inconsistent results.

I understand that I am responsible for the full payment of any medical expenses incurred in the event that medical attention is necessary. This procedure is being performed under standard sanitizing and sterilizing methods as recommended by the Centers for Disease Control and as required by the State Department of Health. All needles are disposed of properly after each procedure.

Ethnic Disclaimer: Hyperpigmentation can occur in certain clients due to an increased amount of melanin in the skin. This occurs more frequently in clients of Indian, Asian, African, Middle Eastern, and similar backgrounds. Hypertrophic scarring or keloids, although rare, can also occur. In the event of either occurrence, treatments will stop.

In consideration of Double Cleanse Skin LLC providing me with the service requested, I hereby release, waive, and discharge Ashley Moran and Double Cleanse Skin LLC from liability for all loss or damage on account of or injury to person. I understand several procedures may be necessary to achieve the desired effect and agree to complete my treatments as recommended. Should I not complete treatments, I will be responsible for any adverse outcome. I expressly agree that this consent, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws in the State of Arizona. I have read this consent, understand all its terms, and execute this release voluntarily and with full knowledge of its significance.

I give permission to Ashley Moran (Double Cleanse Skin LLC) to perform one of the following Circadia treatments: Oxygen Rx Treatment, Cocoa Enzyme, Raspberry Enzyme, or Zymase Enzyme.

I agree to be truthful about my physical conditions, pregnancy, medications I may be taking, and my current skin care regimen. I am aware that my lifestyle, including smoking, outdoor exposure, tanning beds, excessive alcohol consumption, and/or recreational use of controlled substances, will affect and may diminish the effectiveness of the treatment.

I have disclosed to my skin care professional any surgical procedures, laser treatments, or facial procedures I have had or intend to have in the future. I am not presently pregnant or lactating. I have not had any recent chemotherapy or radiation treatments. I have not recently waxed or used a depilatory on the area being treated today. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters, or cold sores.

I understand that I should not have a treatment if I intend to be in the sun or use a tanning bed, and I will refrain from excessive sun exposure and tanning bed use while undergoing treatment. I have disclosed to my skin care professional any treatments of any kind received within 14 days of this treatment, whether at this location or any other.

I understand that although complications are very rare, they may occur, and prompt treatment is necessary. In the event of any complication, I will immediately contact my skin care professional.

My expectations are realistic and I understand that results are not guaranteed. For maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, age, degree of sun damage, and pigmentation levels. I understand that my practitioner will recommend home care products to work in tandem with the in-clinic treatment, and I am willing to follow all home care recommendations including a sunscreen. I consent to the taking of photographs to monitor treatment effects if desired by my skin care professional.

I confirm that NONE of the following conditions currently apply to me:

In the event of any questions or concerns, I will consult my skin care professional immediately. I understand the potential risks and complications and have chosen to proceed after careful consideration of both known and unknown risks, complications, and limitations. I will hold the skin care professional and staff harmless from any liability that may result from this treatment. I agree that this constitutes full disclosure superseding any previous verbal or written disclosures. I certify that I have read and fully understand the above and have had sufficient opportunity to have any questions answered.

I give permission to Ashley Moran (Double Cleanse Skin LLC) to perform a Circadia chemical peel treatment in the form of: Lactic, Alpha/Beta, Jessner’s, DermaFrost Salicylic, or MandeliClear.

I agree to be truthful about my physical conditions, pregnancy, medications I may be taking, and my current skin care regimen. I am aware that my lifestyle, including smoking, outdoor exposure, tanning beds, excessive alcohol consumption, and/or recreational use of controlled substances, will affect and may diminish the effectiveness of the treatment. I have disclosed any surgical procedures, laser treatments, or facial procedures I have had or intend to have in the future.

I am not presently pregnant or lactating. I have not had any recent chemotherapy or radiation treatments. I have not recently waxed or used a depilatory on the area being treated today. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters, or cold sores.

I have not had any other peel treatment of any kind within 14 days of this treatment. I understand I cannot have another treatment within 14 days, whether at this location or any other. I agree to refrain from excessive sun exposure or tanning bed use during treatment and for the 14 days following. I understand that sun exposure is prohibited while undergoing treatment and that Circadia Light Day Broad Spectrum Sunscreen SPF 37 is mandatory.

I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin. Benefits include lessening of pigmentation, reduction in appearance of fine lines and wrinkles, and control of conditions such as acne. I understand the possibility of peeling, flaking, hyperpigmentation, and excessive dryness. Every precaution will be taken to minimize or eliminate negative reactions such as blisters, redness, or irritation.

My expectations are realistic and I understand results are not guaranteed. More than one application may be necessary for maximum results. I understand that my practitioner will recommend home care products to work in tandem with the in-clinic treatment, and I am willing to follow all home care recommendations including a sunscreen. I consent to the taking of photographs to monitor treatment effect and results if desired by my skin care professional.

I confirm that NONE of the following conditions currently apply to me:

In the event of any questions or concerns, I will consult my skin care professional immediately. I understand the potential risks and complications and have chosen to proceed after careful consideration of both known and unknown risks, complications, and limitations. I will hold the skin care professional and staff harmless from any liability that may result from this treatment. I agree that this constitutes full disclosure superseding any previous verbal or written disclosures. I certify that I have read and fully understand the above and have had sufficient opportunity to have any questions answered.