Fillable Printable Microdermabrasion Information Sheet

Microdermabrasion Information Sheet

What is Microdermabrasion?

Microdermabrasion uses an adjustable applicator head that 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.

Microdermabrasion has been used to treat aging and sun-damaged skin, some types of acne

and acne scarring, altered pigmentation, fine lines and wrinkles, and stretch marks. Results

may include improved skin tone, fewer breakouts, diminished appearance of scars, even skin

color, refined skin pores, renewed elasticity, and a healthy glow.

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Client Initials

What should you expect during your treatment?

Prior to your first microdermabrasion, as your esthetician, I will perform a thorough skin analysis.

If microdermabrasion is not appropriate, you are informed during this session and an alternative

treatment may be recommended instead. If microdermabrasion is for you, maximum results are

obtained by participating in a series of treatments plus following a home care regimen.

To further enhance your outcome, I require that you use products specifically directed toward

obtaining correction. Your current daily regimen and skin care projects used will be reviewed,

and you will be instructed which products you should continue to use, and will be advised on

any recommended additions to your regimen. I recommend keeping regular appointments and

carefully following your home care regimen to support your results.

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Client Initials

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 excessive dryness or even some

peeling between sessions, which may or may not be normal. 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 face: therefore, it is to your benefit to continue to

protect it long after your series is completed.

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Client Initials

Is satisfaction guaranteed?

The majority of my clients receive satisfactory to above average results with a series of

treatments. Maximum results are highly dependent on your age, cumulative sun exposure,

health, menopause, lifestyle, genetic traits, general skin condition, and your willingness to

follow recommended protocols.

Be aware that many changes may occur deeper within the skin over time. I find that when

participating in a series of treatments, along with a commitment to your daily skin care

regimen, noticeable differences may indeed be the outcome. You may see a reduction of fine

lines and a softening of deeper wrinkles, reduction of discoloration, softening and possible

reduction in scars, and an overall improvement to the skin’s tone and appearance. To continue

the maintenance of your skin after you complete your treatment(s), I may inform you of long-

term age management programs.

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Client Initials

Microdermabrasion Information Sheet

Continued a

Contraindications

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.

Active infection of any type, such as Herpes simplex virus or flat warts.

Active acne

Sunburn

Recent use of topical agents such as glycolic acids, alphahydroxy acids and Retin-A

Any recent chemical peel procedure

Uncontrolled diabetes

Eczema, dermatitis

Skin cancer

Vascular lesions

Oral blood thinner medications

Rosacea

Tattoos (not effective)

Pregnancy

Use of Acutane within the last year

Family history of hypertrophic scarring or keloid formation

Telangiectasia/erythema may be worsened or brought out by skin exfoliation

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Client Initials

Post-Treatment/Home Care

Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided.

Direct sunlight exposure is to be completely avoided immediately following the treatment

(including any strong UV light exposure and tanning beds). If some sun exposure cannot be

avoided, first apply sunscreen with an SPF of 30 or greater. Although sunscreen should be a

part of your daily skin care, for a minimum of two weeks, a sunscreen with at least a SPF of 15

must be applied.

Cleanse your face with water or a mild soap substitute such as ___________. Twice daily

followed by a mild sunscreen such as _____________________ (minimum SPF 30). If a site

other than the face is treated, you only need to cleanse once daily, followed by sunscreen.

In the event that you may have additional questions or concerns regarding your treatment or

suggested home product / post-treatment care, you must consult your therapist immediately.

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Client Initials

Client Name (printed) ____________________________________________________________________________

Client Name (signature) _____________________________________________ Date________________________

Esthetician _________________________________________________________ Date________________________

Microdermabrasion—Continued

I, ____________________________________, have read the above 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 micro-

dermabrasion procedure we have discussed and will hold her and her staff harmless from any liability that

may result from this treatment. I understand 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 over the counter product or pre-

scription 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, sun-

burn, 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, irrita-

tion, 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.

Client Name (printed) ____________________________________________________________________________

Client Name (signature) _____________________________________________ Date________________________

Esthetician _________________________________________________________ Date________________________

Client Consent—Microdermabrasion