Microdermabrasion Consent Form Name First Last Email* Date of Birth* MM DD YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneMicrodermabrasion Consent:* I understand there are contraindications and I have been informed to not receive treatment if I have any of the following: Active infection of any type, such as herpes simplex or flat warts; Sunburn; Retin A use; recent chemical peels; Accutane use within the last year; eczema, dermatitis; rosacea; family history of keloid formation; uncontrolled diabetes; skin cancer. I understand that possible side effects include but are not limited to: skin tightness, mild to moderate redness, skin sensitivity; excessive dryness or even some peeling between sessions, which may or may not be normal. I understand that aerobic exercise or vigorous physical activity should be avoided until all redness has subsided. 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 a series of treatments are performed and the advised program is followed. I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied. I understand that any injections should be avoided for 10-14 days before this treatment. I understand that direct sun exposure, including tanning booths, is prohibited while undergoing treatment and the use of daily sun block protection to the area treated is mandatory. To further enhance your outcome, we require that you use products specifically directed toward obtaining correction. Your current daily regimen and skin care products 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. We recommend keeping regular appointments and carefully following your home care regimen to support your results. I have read the foregoing 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 care therapist. I give permission to my therapist to perform the microdermabrasion procedure and will hold her harmless from any liability that may result from this treatment. I have given an accurate account of any over the counter or prescription medications that I use regularly and I am not presently using Accutane I have not had any facial surgical procedures, chemical peels or skin treatments within the past 2 weeks. I consent to the taking of photographs to monitor treatment effects as desired or recommended by my therapist. I understand that if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform Dermaplaning procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. If I have any concerns I will consult my Esthetician immediately. Date Signature*NameThis field is for validation purposes and should be left unchanged.