Microdermabrasion Consent Form

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Microdermabrasion is a minimally invasive procedure used to renew overall skin tone and texture. It can improve the appearance of sun damage, wrinkles, fine lines, age spots, acne scarring, melasma, and other skin-related concerns and conditions.

The procedure uses a special applicator with an abrasive surface to gently sand away the thick outer layer of the skin to rejuvenate it.

A different microdermabrasion technique sprays fine particles of aluminum oxide or sodium bicarbonate with a vacuum/suction to accomplish the same outcome as the abrasive surface.

Microdermabrasion is considered a safe procedure for most skin types and colors. People might choose to get the procedure if they have the following skin concerns:

fine lines and wrinkles
hyperpigmentation, age spots and brown spots
enlarged pores and blackheads
acne and acne scars
stretch marks
dull-looking skin complexion
uneven skin tone and texture
melasma
sun damage

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I understand my esthetician will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I have given an accurate account of any over-the-counter or prescription medications that I use regularlyI am not presently using isotretinoin (Accutane) nor I have used it with in the last 12 monthsI have not had any facialsurgical procedures (botox of fillers) or other chemical peels or skin treatments thatI have not disclosed to myesthetician.I am not presently pregnant orlactating and I over the age of eighteenI have not had any recentradioactive or chemotherapy treatments with in the last 12 monthsI do not have a history ofkeloidal scarring, excessive telangiectasia, rosacea, bacterial skininfections, fungal infections, viral infections, open lesions orrashes, active acne, any auto immune disease, or any other existingcondition that may interfere with the positive outcome of thistreatment.I have not recently waxed, or used a depilatory (Such as Nair) on the area to be treated.I consent to the taking of photograph to monitor treatment effects, as desired or recommended by my esthetician.

I have read the above information in each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my esthetician. I give permission to Simply Relaxed to perform the microdermabrasion procedure we have discussed and will hold her harmless from any liability that may result from this treatment.*

My expectations are realistic and I understand that the results are not guaranteed. 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 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). In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician immediately. I understand the potential risks and complications and I 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 certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion and to have any questions answered.*

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.*

Digital submission of this form is your acceptance and agreement

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