"Microdermabrasion Consent Form - Simply Organic Skincare"

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Simply Organic Skincare
Microdermabrasion Consent Form
Today’s Date____________
Name_____________________________________________
Have you ever had a Microdermabrasion Treatment? ______________________________
Any recent chemical peel procedure? List procedure date: _________________________
Recent waxing? Date of wax ___________
Area that was waxed: _____________________
Do you have any current medical conditions? _____
If yes, please list:___________________
What results do you wish to receive from this treatment? _______________________________
What is Microdermabrasion?
Microdermabrasion is a quick and painless treatment that accelerates the rate at which dead skin is exfoliated and jump starts the proliferation
of new skin cells. It removes dead surface skin cells and initiates cellular turnover at the dermis and epidermis levels in a safe controlled
manner. This approach respects the integrity of the skin and promotes even healing. Maintaining even cellular growth on the surface aids in
the youthfulness of the skin’s appearance. Results may include improved skin tone, softening of fine lines and wrinkles, fewer breakouts,
diminished appearance of scars, even skin color, refined skin pores, renewed elasticity, and a healthy glow.
As your esthetician, I take every precaution to ensure that your skin is well hydrated and calm prior to leaving each session. However, you
may experience some dryness or even some peeling/flaking between sessions. Always check with me if you have any concerns after the
treatment. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.
After your treatment, sunblock must be worn at all times and tanning beds should never be used. You are making an investment in your skin:
therefore, it is to your benefit to continue to protect after your service is completed.
Post-Treatment/Home Care
Aerobic exercise or vigorous physical activity should be avoided for 48 hours after treatment. Direct heat to skin should also be avoided
(sauna's, steam rooms, etc). For those who use a Clarisonic Brush or similar device, it is advised you use caution around your microderm
treatments. If doing a weekly series it is highly recommended you discontinue use of the brush until the series is over. It is advised not to use
the brush within three days of receiving a microderm treatment. The same goes for at-home peels. We do not want to over-exfoliate the skin.
Direct sun exposure is to be completely avoided immediately following the treatment (including tanning beds). If some sun exposure cannot
be avoided, first apply sunscreen with an SPF of 15 or 30.
Contraindications - PLEASE CHECK IF ANY OF THESE CONDITIONS EXIST:
Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for
microdermabrasion treatment and must be disclosed prior to treatment.
o
Any contageous disease
o
Blood transmitted diseases(HIV, hepatitis, herpes)
o
Retin-A
o
Tetracycline
o
Use of Accutane (isotretinoin) within the last year
o
Any medications that thin the skin
o
Any medication that causes sensitivity to sun exposure
o
Hemophilia (a rare bleeding disorder where the blood doesn't clot normally)
o
Sunburn, skin irritation or rashes (wait at least 48 hours after waxing)
o
Diabetes (insulin dependent)
o
Cancer
o
Pregnancy
o
Family history of hypertrophic scarring or keloid formation (if you keloid easily, microderm is not recommended)
o
Currently under doctor's care (must provide a doctor's note giving permission to perform the service)
_____________
*Client Initials
I give permission to my esthetician to perform the microdermabrasion procedure 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 as much as
possible. 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 over-the-counter product or prescription medication/agent that has not been disclosed. 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 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). 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.
Client Signature ______________________________________________Date ________________________
Simply Organic Skincare
Microdermabrasion Consent Form
Today’s Date____________
Name_____________________________________________
Have you ever had a Microdermabrasion Treatment? ______________________________
Any recent chemical peel procedure? List procedure date: _________________________
Recent waxing? Date of wax ___________
Area that was waxed: _____________________
Do you have any current medical conditions? _____
If yes, please list:___________________
What results do you wish to receive from this treatment? _______________________________
What is Microdermabrasion?
Microdermabrasion is a quick and painless treatment that accelerates the rate at which dead skin is exfoliated and jump starts the proliferation
of new skin cells. It removes dead surface skin cells and initiates cellular turnover at the dermis and epidermis levels in a safe controlled
manner. This approach respects the integrity of the skin and promotes even healing. Maintaining even cellular growth on the surface aids in
the youthfulness of the skin’s appearance. Results may include improved skin tone, softening of fine lines and wrinkles, fewer breakouts,
diminished appearance of scars, even skin color, refined skin pores, renewed elasticity, and a healthy glow.
As your esthetician, I take every precaution to ensure that your skin is well hydrated and calm prior to leaving each session. However, you
may experience some dryness or even some peeling/flaking between sessions. Always check with me if you have any concerns after the
treatment. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.
After your treatment, sunblock must be worn at all times and tanning beds should never be used. You are making an investment in your skin:
therefore, it is to your benefit to continue to protect after your service is completed.
Post-Treatment/Home Care
Aerobic exercise or vigorous physical activity should be avoided for 48 hours after treatment. Direct heat to skin should also be avoided
(sauna's, steam rooms, etc). For those who use a Clarisonic Brush or similar device, it is advised you use caution around your microderm
treatments. If doing a weekly series it is highly recommended you discontinue use of the brush until the series is over. It is advised not to use
the brush within three days of receiving a microderm treatment. The same goes for at-home peels. We do not want to over-exfoliate the skin.
Direct sun exposure is to be completely avoided immediately following the treatment (including tanning beds). If some sun exposure cannot
be avoided, first apply sunscreen with an SPF of 15 or 30.
Contraindications - PLEASE CHECK IF ANY OF THESE CONDITIONS EXIST:
Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for
microdermabrasion treatment and must be disclosed prior to treatment.
o
Any contageous disease
o
Blood transmitted diseases(HIV, hepatitis, herpes)
o
Retin-A
o
Tetracycline
o
Use of Accutane (isotretinoin) within the last year
o
Any medications that thin the skin
o
Any medication that causes sensitivity to sun exposure
o
Hemophilia (a rare bleeding disorder where the blood doesn't clot normally)
o
Sunburn, skin irritation or rashes (wait at least 48 hours after waxing)
o
Diabetes (insulin dependent)
o
Cancer
o
Pregnancy
o
Family history of hypertrophic scarring or keloid formation (if you keloid easily, microderm is not recommended)
o
Currently under doctor's care (must provide a doctor's note giving permission to perform the service)
_____________
*Client Initials
I give permission to my esthetician to perform the microdermabrasion procedure 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 as much as
possible. 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 over-the-counter product or prescription medication/agent that has not been disclosed. 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 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). 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.
Client Signature ______________________________________________Date ________________________