Microdermabrasion Client Consent Form printable pdf download

Lisa’s Salon and Day Spa

Microdermabrasion Client Consent Form

Patient: ___________________________________________________

Date: _____________________

This consent form is designed to verify that you have been informed and educated in respect to you

microdermabrasion skin care treatment, as well as its aftercare.

This disclosure is to inform you before your consent for treatment. Please read and initial where indicated.

I acknowledge having been informed that this cosmetic procedure is intended to remove super cial

surface layers of the skin to improve the vitality of the skin. Initial here: ______

I understand that I cannot have Microdermabrasion done if I currently have any conditions listed:

Pregnancy, Active infection of any type, such as Herpes simplex virus or at warts, Active acne, Sunburn.

Recent use of topical agents such as Glycolic acids, Alpha-hydroxy acids and Retin-A or any recent chemical

peel procedure. Uncontrolled Diabetes, Eczema, Dermatitis, Rosacea, Skin cancer or Vascular lesions.

Oral blood thinner medications.

Initial here: ______

It has been explained to me that because microdermabrasion procedures are a super cial abrasion

to the skin, the result of a one-time treatment is similar to a deep cleansing or polishing of the skin.

I understand that in order to see signi cant results these treatments need to be done in a series and in

combination with after care and skin care products. Initial here: ____

I acknowledge that after my microdermabrasion procedure, all treated areas may feel warm and appear

sunburned or my skin may experience a wind-burned sensation. Initial here: _____

I understand that my compliance to my after care instructions will greatly a ect my nal result.

I acknowledge my obligation to follow the written and spoken instructions covering my pre- and post

-treatment skin care regimen. Initial here: ____

I understand that multiple treatments may be required. Initial here: _____

I understand that although rare, certain risks or complications could occur but are usually treatable and

temporary, such as hyper-pigmentation, hypo- pigmentation, and scarring. Following all post procedure

instructions will help

avoid conditions. Initial here: _____

I acknowledge that if I am prone to Herpes (cold sores, fever blisters) I need to avoid treatments during

a breakout.

Initial here: _____

9. I acknowledge that I have not used Accutane during the last six months. Initial here: _____

10. I acknowledge that I should avoid the use of glycolic and Retin-A type products for seven days before and

following treatment.

Initial here: _____

11. Acne patients, it has been explained to me that I may experience a slight acne are-up, and that my acne

condition may temporarily look worse for a few days after a microdermabrasion treatment. Initial here: _____

12. I acknowledge that I have been instructed to avoid sun exposure and must wear a sun block of at least SPF 30 over

the treated areas on a daily basis during my treatment series. Initial here: _____

13. I understand that if I have any additional questions or concerns that I should call the o ce immediately. Initial

here: _____

have read and initialed each paragraph and have been satisfactorily informed of the bene ts, risks, andcomplications regarding microdermabrasion.

I consent to this microdermabrasion treatment today and for all subsequent microdermabrasion treatments.

Patient Signature: ___________________________________________

Date: _____________________

Technician Signature: __________________________________________

Date: _____________________

Parent/Legal Guardian Signature (if patient is a minor): ___________________ Date:_____________________

Microdermabrasion Client Consent Form

Related Articles

Related forms

Related Categories