Microdermabrasion Consent Form
Full Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Email Address
example@example.com
Emergency Contact
Which skin issues concern you most about your appearance and your skin? (check all that apply)
Bumpy Skin
Cysts/ Nodules
Dull Complexion
Blackheads
Acne
Acne Scars
Age Spots
Facial Veins
Wrinkles
Breakouts
Large Pores
Melasma
Redness
Sun Damage
Dark Pigmentation
How would you describe your skin?
Dry
Oily
Combination
Sensitive
How would you describe your stress level?
Little
Moderate
Severe
Please select the skin care products you currently are using
Cleanser
Moisturizer
Exfoliater
Toner
Sunscreen
Retinol
Glycolic Acid
INK BEAUTIQUE
Medical Questionnaire
The following conditions are recognized as contraindications for PMU and must be disclosed and discussed with the specialist prior to treatment. Please check all that apply and give details below:
Accutane Treatment
Chemotherapy / Radiation
Any medical condition that compromises skin.
Are you currently taking any medication?
Yes
No
Please list
Do you have any allergies?
Yes
No
Do you tan in the sun or in tanning beds/booths?
Yes
No
Do you get Laser Treatment or Chemical Peels?
Yes
No
Please check each box to show your understanding and agreement
I am over the age of 18
I am not under the influence of drugs or alcohol.
I desire to receive the indicated Microdermabrasion procedure.
If an unforeseen condition arises in the course of the procedure I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances.
I fully understand and accept that non-toxic serums are used during the procedure.
I have been informed that the highest standards of hygiene are met for each individual client procedure and visit.
I understand and accept that each procedure is a process requiring multiple applications to achieve desired results and that 100% success cannot be guaranteed during the first procedure.
The result of the procedure can be affected by the following: medication, skin characteristics (dry oily sun-damaged thick or thin skin type) personal pH balance of your skin alcohol intake and smoking post procedure after care.
Sunscreen is highly recommended on a daily basis.
Normal activities can be continued following the procedure.
I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may lower my chances for a successful procedure.
I accept full responsibility for the decision to have Microdermabrasion done.
We have your consent to take your photos for education purposes and post them online on my social media.
I understand the Microdermabrasion treatment carries with it known and unknown complications and consequences associated with this type of cosmetic procedure including but not limited to: bruising & redness.
I give Manmeeth Brar permission to perform my Microdermabrasion procedure. By my signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.
Signature
Date
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Month
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Day
Year
Date
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