Microdermabrasion Consent Form

  • MM slash DD slash YYYY
  • 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.
  • 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 all that apply
  • What are you currently using on your skin, include any professional or drug store products you use.
  • Check all that apply
  • Check all that apply
  • LIst any allergies you may have, include products, medications, seasonal, environmental etc. If none list N/A
  • Please check all that apply
  • List when and what type of treatment you received
  • Remember to list birth control if applicable
    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.
    If yes, you will need to consult with your Dr. prior to scheduling an appointment and provide details below.
    If yes, you will need to consult with your doctor about getting skin care treatments.
  • 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.
  • 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 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.
  • MM slash DD slash YYYY