Chemical Peel/ Microdermabrasion/ Hydrodermabrasion Consent Form
Chemical Peel/Microdermabrasion/Hydrodermabrasion is often used to treat acne, reduce the appearance of scars, wrinkles, hyperpigmentation and other skin conditions. A series of treatments is recommended for optimal results.
Client Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
I give my skin therapist permission to perform the chemical peel and/or microdermabrasion/hydrodermabrasion treatment we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment.
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Yes
I understand he/she will take every precaution to minimize or eliminate negative reactions as much as possible.
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Yes
I have given an accurate account of any over-the-counter or prescription medications that I use regularly and I am not presently using isotretinoin (Accutane).
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Agree
I have not had any facial surgical procedures or other chemical peels or skin treatments that I have not disclosed to my therapist.
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Agree
I am not ingesting or using topically any other over-the-counter product or prescription medication/agent that has not been disclosed to my therapist.
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Agree
I am not presently pregnant or lactating.
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Agree
I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin
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Agree
I have not recently waxed or used a depilatory (such as Nair) on the area to be treated within the last 72 hours.
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Agree
I do not have a history of keloidal scarring, excessive telangiectasia, rosacea, bacterial skin infections, fungal infections, viral infections, open lesions or rashes, active acne, any auto immune disease, or any other existing condition that may interfere with the positive outcome of this treatment.
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Agree
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 of at least SPF30 and avoiding the sun/tanning booths and extreme weather conditions.
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Yes
I agree to use a moisturizer specifically recommended by my esthetician and I 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).
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Yes
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.
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Yes
My expectations are realistic and I understand that the results are not guaranteed. Several treatments may be needed to improve the skin condition.
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Yes
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.
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Yes
Client's Signature
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Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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