Fillable Printable Microdermabrasion Client Informed Consent Form

Microdermabrasion Client Informed Consent Form

Microdermabrasion

Client Informed Consent Form

To the CLIENT: You have a right to be informed about your condition and its treatment, so that you make the

decision whether or not to undergo the procedure after knowing the risks and hazards involved. This

disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may

give, or withhold, your consent for treatment.

1. I voluntarily request that ___________________________ (and such associates, technical

assistants and other skincare professional she or he may deem necessary) to perform the

Microdermabrasion procedure. I acknowledge having been informed that this cosmetic

procedure is intended to remove surface layers of the skin to improve the vitality of the skin.

2. I understand that my skincare professional can discover other, or different conditions that may

require additional or different procedures than those planned. If my skincare professional

discovers such other or different conditions I will be referred to appropriate medical care

provider.

3. I acknowledge that, while the goal of such a procedure is the removal of damaged skin, the

realistic results average 50-75% improvement. I acknowledge that the practice of

cosmetology is not an exact science and that no specific guarantees can or have been made

concerning the expected result. Some clients are improved and in others no appreciable

improvements is noticed.

4. I also realize that the following risks and hazards may occur in connection with the particular

procedure; worsening or unsatisfactory appearance, creation of additional problems such as:

poor healing or skin loss, nerve damage, painful unattractive scarring, or recurrence or the

original condition.

5. I have been advised that I must use sunscreen of SPF 25 or greater at all times through out the

course of treatment.

6. I have been informed that there are risks such as loss of blood and infection that are attendant

to the performance of any exfoliation procedure.

7. I have been advised of alternative methods available for my treatment, which includes acid

peels and laser skin resurfacing.

8. I acknowledge my obligation to follow the written and spoken instructions covering my pre

and post treatment skincare regimen.

9. I understand that multiple treatments may be required. The cost of these was disclosed prior

to the first treatment.

10. I have received a thorough explanation of my pre-exfoliation and post-exfoliation

instructions. I understand these instructions and have received copies for reference. I

understand that should I have additional questions, I should not hesitate to call.

I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for

discussion and all my questions have been answered to my satisfaction. I hereby consent to the

Microdermabrasion procedure. This constitutes the full disclosure and supersedes any previous verbal or

written disclosures.

Client’s Name (Please Print):

Client’s Signature:

Date: Time: