MICRODERMABRASION CONSENT FORM
1. Prior to receiving this treatment, I have been candid in revealing any condition that may
have a bearing on this procedure, such as pregnancy, recent facial peels or surgery,
allergies, tendencies to cold sores and fever blisters, use of Retin-A, Accutane or
2. I understand there may be some degree of minor discomfort, i.e., scratchiness, itchiness.
3. I understand there are no guarantees to this procedure.
4. I understand that to achieve maximum results, I will need several ongoing treatments
and use a daily product over a period of time.
5. I understand that the possibility of irritation and redness exists and that I should notify
my skin care professional when irritation persists.
6. I will follow the home care program specifically designed for me without changing or
adding any products without consulting with my skin care professional.
7. I have read the enclosed consultation and understand the contents.
I agree to all of the above to have this treatment performed on me and will follow all prescribed directions regarding post peel care.
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