Microdermabrasion Consent Form

NOTE: This form is required to be filled out prior to a client's first Microdermabrasion facial at Simply You Skincare & Wellness.

Date*

Date

Name*

First NameLast Name

What Is Microdermabrasion?

Microdermabrasion uses an adjustable applicator head that removes dead surface skin cells and initiates cellular turnover at the dermis and epidermis levels in a safe controlled manner. This approach respects the integrity of the skin and promotes even healing.

Microdermabrasion has been used to treat aging and sun-damaged skin, some types of acne and acne scarring, altered pigmentation, fine lines and wrinkles, and stretch marks. Results may include improved skin tone, fewer breakouts, diminished appearance of scars, even skin color, refined skin pores, renewed elasticity, and a healthy glow.

What Should You Expect During Your Treatment?

Prior to your first microdermabrasion, as your esthetician, I will perform a thorough skin analysis. If microdermabrasion is not appropriate, you are informed during this session and an alternative treatment may be recommended instead. If microdermabrasion is for you, maximum results are obtained by participating in a series of treatments plus following a home care regimen. I recommend keeping regular appointments and carefully following your home care regimen to support your results.

As your esthetician, I take every precaution to ensure that your skin is well hydrated and calm prior to leaving each session. However, you may experience excessive dryness or even some peeling between sessions, which may or may not be normal. Always check with me if you have any concerns after the treatment. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.

After your treatment, sunblock must be worn at all times and tanning beds should never be used. You are making an investment in your face: therefore, it is to your benefit to continue to protect it long after your series is completed.

Is Satisfaction Guaranteed?

The majority of my clients receive satisfactory to above average results with a series of treatments. Maximum results are highly dependent on your age, cumulative sun exposure, health, menopause, lifestyle, genetic traits, general skin condition, and your willingness to follow recommended protocols.

Contraindications

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for microdermabrasion treatment and must be disclosed prior to treatment:

Active infection of any type, such as Herpes simplex virus, blisters, or flat warts
Active acne
Sunburn or windburn
Use of some topical agents, including Retin-A
Any recent chemical peel procedure
Eczema/Dermatitis
Skin cancer
Vascular lesions
Rosacea
Pregnancy
Use of Acutane within the last year
Family history of hypertrophic scarring or keloid formation

I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand that if I have any concerns, I will address these with my esthetician. I give permission to Allie Bebenroth (esthetician) to perform the microdermabrasion procedure we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I agree that I am willing to follow recommendations by my esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I also acknowledge that I have been informed of the possible negative reactions and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.*

I agree

Signature*