Microdermabrasion Consent Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Please read and check the box once you understand each statement. Consent Checkoff* I understand that there may be a burning sensation or stinging may occur during the treatment. I understand that possible side effects include but are not limited to: peeling, tightness, mild to extreme redness, suction marks, wind-burn sensations, dry skin, flaking skin, and/or lightening or darkening of the skin. I understand that the results of this treatment may vary due to conditions: such as age, condition of skin, sun damage, damage due to smoking, climate etc. I understand that the number of treatments is dependent on skin type and condition, and that the best results are achieved when the advised program is followed. I understand that the treatment is a cosmetic treatment and that no medical claims are expressed or implied. I understand that if I'm prone to cold sores around the mouth they may result after this treatment. I understand that waxing, collagen injections, and Botox injections should be avoided for 10-14 days before or after this treatment. I understand that direct sun exposure, including tanning booths, is prohibited while I am undergoing treatment and that the use of daily sun block protection (minimum SPF 30) to the area treated is mandatory. I have not had a chemical peel or microdermabrasion treatment of any kind within 14 days of this treatment, whether the treatment was performed at this location or any other location. I understand that I am to discontinue all AHA's Glycolics, Retin-A, Renova or any exfoliating products for up to 72 hours pre-and post-treatment. SignatureDate* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
