I have read the given information and initialed each section to indicate that
I fully understand what to expect. If I have any questions or concerns, I
will address these with my skin therapist. I give permission to my therapist
to perform the microdermabrasion procedure we have discussed and will hold
him/her and his/her staff harmless from any liability that may result from
this treatment. I understand he/she 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 regularly and I am
not presently using isotretinoin (Accutane). I have not had any facial
surgical procedures or other chemical peels or skin treatments that I have
not disclosed to my therapist. I am not ingesting or using topically any
other overthe-counter product or prescription medication/agent that has not
been disclosed to my therapist. I am not presently pregnant or lactating and
I am over the age of eighteen (18). I have not had any recent radioactive or
chemotherapy treatments, sunburn, windburn, or broken skin. I have not
recently waxed or used a depilatory (such as Nair) on the area to be
treated. I do not have a history of keloidal scarring, excessive
telangiectasia, rosacea, bacterial skin infections, fungal infections, viral
infections, open lesions or rashes, active acne, any auto immune disease, or
any other existing condition that may interfere with the positive outcome of
this treatment.
I consent to the taking of photographs to monitor treatment effects, as
desired or recommended by my therapist.
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 agree to use a moisturizer specifically
recommended by my esthetician and 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
therapist immediately.
I understand the potential risks and complications and 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
to have any questions answered.
