CLIENT QUESTIONNAIRE - Microdermabrasion

  • CLIENT QUESTIONNAIRE - Microdermabrasion

  • MEDICAL INFORMATION:

  • Accutane Used:*
  • Glycolic, Salicylic Acid, Alpha or Beta Hydroxy Products Treatments, If yes, when?*
  • Retin A, Renova, If yes, when?*
  • Do You Have any Allergies?*

  • CLIENT QUESTIONNAIRE - Microdermabrasion

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  • Do you have any of the following?
  • Currently under the care of a physician?*
  • Previous laser procedures, chemical peel, dermabrasion*

  • CLIENT QUESTIONNAIRE - Microdermabrasion

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  • 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*
  • 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.*
  • In doing Microdermabrasion, my interest is primarily for*
  • Have you had in the past 2 weeks

  • 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)

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