Microdermabrasion Consent Form

3141 E Broad St Suite 303 Room 114, Mansfield, TX 76063
(682) 213-0798
lealux.glossgenius.com
Microdermabrasion Consent Form
Client Details
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone*
Please enter a valid phone number.
Email*
example@example.com

Treatment Information
What is microdermabrasion?

Microdermabrasion projects a flow of inert crystals over the skin, and abrades away epidermal tissue in the areas treated. It is done so precisely that normal surrounding tissue is hardly affected. Microdermabrasion is often used to treat acne, reduce the appearance of scars, wrinkles, hyper pigmentation and other skin conditions.

What to expect
- After a treatment, the skin may temporarily be red and feel tight and warm as if exposed to the sun or wind.
- Slight redness and swelling may appear with deeper treatment levels, in addition to slight blood spotting.
- Healing may take several days or longer.

Aftercare Instructions
After the procedure, your fresh newly exposed skin will be delicate. Therefore, it is important that you follow these instructions. Any time the skin barrier is broken there is a small risk of bacterial or viral infection.
- Use a mild cleanser and keep the skin well moisturized.
- Use a full spectrum sun block (30+ SPF) daily.
- Avoid the use of Retin-A, Renova for at least 7-10 days after.
- Avoid alpha or beta hydroxyl type products and all scrubs for at least 5 to 7 days after, or until initial sensitivity subsides.
- Avoid swimming and tanning beds for at least one week after.

Consent

Please check each box to show your understanding and agreement.

Signature

This agreement will remain in effect for this procedure and all future microdermabrasion procedures. I will alert the skincare specialist if there are any future changes to my medical history. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the microdermabrasion procedure.
Signature*

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A copy of this signed agreement will be emailed to you.
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