Microdermabrasion Consent Form

Microdermabrasion Consent Form
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Patient Name
First NameLast Name
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Gender
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Date of Birth
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Email
example@example.com
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Address
Street Address
Street Address Line 2
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Occupation
Consent
DEFINITION: Microdermabrasion is a treatment procedure that is used in order to clean and remove the dead surface skin cells which improve the skin quality and promote skin healing.
AUTHORIZATION: I authorize this beauty clinic to perform this treatment called Microdermabrasion on my skin.
GUARANTEE: I understand that this procedure does not guarantee any results and each individual has their own treatment outcome. We can continue the treatment until the expected result comes out.
INSTRUCTIONS: I confirm that I understand the instructions provided to me by the therapist. I will follow the post-care instructions in order to prevent any complications or negative outcomes. This include:
- Use sunblock daily with an SPF 30
- Avoid swimming and tanning
- Avoid using facial scrubs 24-48 hours after treatment
- Only use a mild cleanser
CONTRAINDICATIONS: I understand that this procedure has contraindications which means that it is recommended not to proceed with the treatment if you have the following:
- Active acne
- Sunburn
- Eczema
- Dermatitis
- Skin Cancer
- Tattoos
- Permanent Make up
- Pregnancy and breastfeeding
- Undergoes hair waxing or hair removal
- Infection like Herpes Simplex Virus
- Diabetes
- Undergoes any chemical peeling
Do you have any of the following contraindications listed above?
YesNo
PHOTO CONSENT: Do you allow or permit this clinic to take photos of your face for marketing purposes? This includes banners, tarpaulin, websites, and social media.
YesNo
RELEASE: I release the clinic and the therapist and hold them harmless from any liability that might happen during and after the treatment.
Patient Signature
Clear
Date Signed
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Date
Witness Name
First NameLast Name
Witness Signature
Clear
Date Signed
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Date
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