CLIENT QUESTIONNAIRE - Microdermabrasion

I agree that I will wear a minimum of SPF 30 on my skin that has been treated as part of my daily routine regime*

YesNo

I understand that I am to discontinue all AHA’s, Glycolics, Retin-A, Renova or any exfoliating products for up to 72 hours post treatment. I understand that rare side effects may result from facials, peels, microdermabrasion,and clarifusion such as: red marks, rashes, hyperpigmentation, superficial burns, and scarring.*

YesNo

In doing Microdermabrasion, my interest is primarily for*

Pigmentation, scarring, etc:Specific areas of concern: eyes, mouth, forehead, etc:Other

Have you had in the past 2 weeks

WaxingSun BurnElectrolysis

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-care instructions. Prior to receiving any treatment, I have been candid in revealing any condition that may have bearing on this procedure. I am over 18 years of age. (Parental consent required for minors)

Signature

Please upload a photo ID *

Browse Files

CLIENT QUESTIONNAIRE - Microdermabrasion

MEDICAL INFORMATION:

CLIENT QUESTIONNAIRE - Microdermabrasion

CLIENT QUESTIONNAIRE - Microdermabrasion