Microdermabrasion Consent – Celebrity Skin Studio

Date*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Phone*

Email*

Date of Birth*

Current Age*

If you are a minor, in addition to this form, you must fill out a General Intake & Waxing consent form, including the parental consent portion. That form is located on the website under the FORMS tab

How did you hear about us? If referred by a friend who should we thank?*

Please indicate how you heard about Celebrity Skin Studio so we know what’s working for us! Please be as specific as possible. Thank you!

What to expect from Diamond Derm-Abrasion

The treatment you will receive is designed to exfoliate the outer layers of the skin. Diamond Microdermabrasion is a non-chemical, non-invasive procedure that uses diamond tips to exfoliate the surface of the skin, while the power of vacuum suction removes dead skin cells and debris. It is very similar to chemical peeling since it removes superficial skin where imperfections are found; however, it is much less aggressive. Microdermabrasion enhances luminosity and eliminates imperfections such as blemishes, wrinkles, scars, and acne. You may notice younger, healthier-looking skin after just your first treatment. Microdermabrasion also stimulates the production of an underlying layer of skin cells with higher levels of collagen and elastin, which further improves your skin’s appearance. It also increases circulation and lymphatic drainage with can reduce puffiness. This treatment is suitable for most skin types and will not cause any scarring, color changes, or discomfort. It is not recommended for extremely sensitive skin such as inflamatory acne, or skin that has lots of broken blood vessels. If you have a cold sore, the appointment should be rescheduled. Your participation in you skin care treatments will help determine the outcome. It is important that you strictly adhere to the home care products that your esthetician has recommended. No guarantee is expressed or implied as to the precise results. This is a relaxing and comfortable procedure. On occasion, during the treatment you may experience some temporary very mild stinging. This will fade within a few minutes. Because we are exfoliating the skin, it’s very important to protect your skin with SPF.

Check the skin care concerns you would like to improve*

Check all that apply

Fine Lines/Wrinkles
Pigmentation/Dark Spots
Acne Scars
Reduction of Redness
Reduction of Oil or Acne
None of the Above

Have you had Micro Dermabrasion before?*

Yes
No

If yes, when?

What is your current skin care routine?*

What are you currently using on your skin, include any professional or drug store products you use.

Which Skin Conditions best describes your skin?*

Check all that apply

Oily
Acne
Dry/Dehyrated
Rosacea/Redness
Normal

Smoking History*

Check all that apply

I do not smoke and have never been a smoker
Previous smoker
Live with a smoker
I currently smoke

Allergies*

LIst any allergies you may have, include products, medications, seasonal, environmental etc. If none list N/A

Have you been treated for any of the following?*

Please check all that apply

Cancer
Acne
Skin Disease
Diabetes
Depression
Blood Pressure
None of the above

If you checked any boxes above please provide information

List when and what type of treatment you received

List any other medical conditions here if none list N/A*

List any Medications if none list N/A*

Remember to list birth control if applicable

Are you pregnant or nursing?*

Yes
No

Are you prone to cold sores?*

Yes
No

If yes, you will need to consult your doctor to see if they recommend having you start a course of antiviral medication prior to your appointment.

Have you used any glycolic products in that last 24 hours?*

Yes
No

Have you used any retinols in the last 72 hours?*

Yes
No

Have you taken Accutane in the last year?*

Yes
No

Are you currently under the care of a Dermatologist or using any prescription products for your skin?*

Yes
No

If yes, you will need to consult with your Dr. prior to scheduling an appointment and provide details below.

If you answered yes to the above questions please indicate what your are being treated for and what medications you are using.

Have you had radiation treatments?*

Yes
No

If yes, you will need to consult with your doctor about getting skin care treatments.

Have you had any recent Skin Care or Cosmetic procedures?

List any medical or cosmetic procedures such as injections, resurfacing treatments/laser or chemical peels, surgeries etc. that have been received within the last year. It is important to keep your technician updated on any procedures received.

I agree to use SPF daily. SPF 30 or greater is recommended.*

By checking the box I agree to comply.

I agree not to wax 7 days before or after my Microdermabrasion session*

By checking the box I agree to comply.

I agree not to use Retin-A (retinol products) 5 days before or after my Microdermabrasion*

By checking the box I agree to comply.

I agree to follow up with scheduled appointments recommended by my esthetician.*

By checking the box I agree to comply.

PRE & POST Treatment instructions

BEFORE Your Treatment: If possible arrive with no make up and cleansed skin. You must discontinue any products with Glycolic Acid at least 24 hours before your appointment. You must discontinue Retinol products of any kind at least 5 days prior to your appointment. You should not have any waxing services done on the treatment area within 7 days before or after treatment. Be sure to disclose any medications you are taking (oral or topical). Do not do Microderm-abrasion within 2 weeks of getting any injections such as botox or filler in the area to be treated.

AFTER your Microdermabrasion: Do not wax the area for 7 days after. Do not use Retinol for 5 days. Don’t use Glycolics or other aggressive products for a couple of days after your appointment. Wear sunscreen daily.

I understand and agree to follow the PRE and POST Peel instructions listed above.

Consent for Treatment and Liablity Waiver*

I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform treatments/procedures and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand 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 been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.

By checking the box and signature below, I agree to Consent for Treatment and Liability Waiver

Signature*

Date*

Microdermabrasion Consent Form

What to expect from Diamond Derm-Abrasion

PRE & POST Treatment instructions

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