Microsoft word - microdermabrasion consent form.doc

Microdermabrasion Client Informed Consent Form
Patient: ___________________________________________________
Date: _____________________
This consent form is designed to verify that you have been satisfactorily informed and educated in respect to your microdermabrasion skin care treatment, as well as its aftercare, so that you may make an educated decision as to whether to have this procedure performed. This disclosure is not meant to alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment. Please read and initial where indicated. 1. I acknowledge having been informed that this cosmetic procedure is intended to remove superficial surface layers of the skin to improve the vitality of the skin. Initial here: ______
2. I understand that my skin care professional can discover other, or different conditions that may require additional or different procedures than those planned. If my skin care professional discovers such other or different
conditions I will be referred to an appropriate medical care provider. Initial here: ______
3. It has been explained to me that because microdermabrasion procedures are a superficial abrasion to the skin, the result of a one-time treatment is similar to a deep cleansing or polishing of the skin. I understand that in order to see significant results these treatments need to be done in a series and in combination with active ingredient skin
care products. Initial here: _____
4. I acknowledge that while the goal of such a procedure is the removal of damaged skin, the realistic results average at least fifty percent improvement. I acknowledge that the practice cosmetology is not an exact science and that no specific guarantees can or have been made concerning the expected result. Some clients’ skin may show
improvement, while others may not show marked improvement. Initial here: _____
5. I acknowledge that after my microdermabrasion procedure, all treated areas may feel warm and appear sunburned or my skin may experience a wind-burned sensation. Initial here: _____
6. I understand that my compliance to my after care instructions will greatly affect my final result. I acknowledge my obligation to follow the written and spoken instructions covering my pre- and post-treatment skin care
regimen. Initial here: _____
7. I understand that multiple treatments may be required. Initial here: _____
8. I understand that although rare, certain risks or complications could occur but are usually treatable and temporary, such as hyper-pigmentation, hypo-pigmentation, and scarring. Following all post procedure instructions will help
avoid conditions. Initial here: _____
9. I acknowledge that if I am prone to Herpes (cold sores, fever blisters) that I may need a prescription for Valtrex (acyclovir) from WSWH prior to having microdermabrasion. I need to avoid treatments during a breakout.
Initial here: _____
10. I acknowledge that I have not used Accutane during the last six months. Initial here: _____
11. I acknowledge that I should avoid the use of glycolic and Retin-A type products the day before, the day of, and
1—3 days following treatment. Initial here: _____
12. Acne patients, it has been explained to me that I may experience a slight acne flare-up, and that my acne
condition may temporarily look worse for a few days after a microdermabrasion treatment. Initial here: _____
13. I acknowledge that I have been instructed to avoid sun exposure and must wear a sun block of at least SPF 25 over the treated areas on a daily basis during my treatment series. Initial here: _____
14. I understand that if I have any additional questions or concerns that I should call the office immediately. Initial
here: _____

I have read and initialed each paragraph and have been satisfactorily informed of the benefits, risks, and complications
regarding microdermabrasion. I consent to this microdermabrasion treatment today and for all subsequent Patient Signature: ___________________________________________ Witness Signature: __________________________________________ Parent/Legal Guardian Signature (if patient is a minor): _____________________________ Date:____________ West Suburban Women’s Health at Antares Med Spa 545-E Plainfield Road, Willowbrook, IL 60527 630.321.2296

Source: http://www.wswomenshealth.com/pdf/Microdermabrasion_Consent_form.pdf

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