Microdermabrasion Consent Form

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.

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.  

Your fresh newly exposed skin will be delicate.  It is important to use a mild cleanser and keep the skin well moisturized.  Use a full spectrum sun block daily.  Avoid the use of Retin-A or Renova for at least 7-10 days after. Avoid alpha or beta hydroxyl acid type products and all scrubs for at least 48 hours after or until initial sensitivity subsided.  Avoid swimming and tanning beds for at least one week after.  Any time the skin barrier is broken there is a small risk of bacterial or viral infection.  

Please initial the first line in each of the following: 

    Client	     Therapist

_______    _______   I acknowledge that I have not used Accutane during the last 6 months.	

_______    _______   I acknowledge that IF I am prone to Herpes (cold sores, fever blisters) I have consulted my physician 
                                   and I am taking an antiviral to reduce the chance of a breakout.  I should avoid treatments during a 
       breakout.

_______    _______   I acknowledge I must reveal any condition that may have a bearing on this procedure, such as 
                                   Pregnancy, allergies,facial waxing, medication use, diabetes or immunodeficiency, prior to 
                     receiving treatment. 

_______    _______   I acknowledge that I should avoid use of glycolic acid or Retin-A type products for 7-10 days following 
       the treatment.

_______    _______   I acknowledge that no guarantee has been given to me regarding the condition of 
                                   my skin or the percentage of improvement expected following treatment.  I understand that no          
                                   specific results are guaranteed.

_______    _______   I understand that I must wear a sun block with an SPF of at least 20 at all times while outdoors to avoid hyperpigmentation that may occur.

My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree 
to the treatment.  I hereby give consent to ___________________ to perform a microdermabrasion treatment. 
I hold harmless __________________________, its employees, student and affiliates of any and all circumstances that may                                                                               occur during my treatment.  By signing below I acknowledge the information provided is true and correct to the best of my                                                              knowledge of this Microdermabrasion Consent Form.  

Client Signature ____________________________________________		Date ____________________________

Student Signature __________________________________________		Date ____________________________

CLIENT INTAKE UPDATE

DATE	
  CLIENT SIGNATURE		
THERAPIST