Microdermabrasion Consent
Patient ____________________________________ Date ____________________________
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I acknowledge that I have not used Accutane during the last 6 months
I acknowledge that I will need to avoid exfoliating treatments during a breakout
I acknowledge that I must reveal any condition that may have a bearing on this
procedure such as pregnancy, allergies, facial waxing, medication use, diabetes, or
immune deficiencies prior to receiving treatment
I acknowledge that there is no guarantee that dark discoloration of the skin will be
reduced or faded. Pigmentation may improve with successive treatments and proper
skin care regimen
I acknowledge that my skin may experience temporary tightness, redness, or slight
swelling which usually dissipates within 24 hours depending on skin sensitivity
I acknowledge that if I fail to use adequate sunscreen (SPF 15 or greater), I am more
susceptible to sunburn and skin damage
I acknowledge that treatment is a strictly elective cosmetic procedure and that no
medical claims are expressed or implied
I acknowledge that I should avoid the use of Retin-A products for 2-4 days following
microdermabrasion.
I hereby agree to have microdermabrasion performed, and I agree to follow pre and post
treatment instructions.
Medical Information:
Check all of the following that pertain to you.
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Accutane
Allergies
Asprin
Autoimmune Disease, HIV
Birth Control Pills, Hormones
Bruise easily, cuts
Diabetes
Eczema
Herpes, Cold Sores
LUPIS, Hepatitus
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Keloids
Warts
Alcohol
Smoke
Laser Procedures, Chemical Peels
Microdermabrasion
Sunburn
Stretch Marks
Pregnancy Breastfeeding
Taking Medication (list all)
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My interest in microdermabrasion is primarily for (i.e. skin rejuvenation, acne, hyper pigmentation, scarring, etc.)
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Specific areas of concern (i.e. eyes, mouth, forehead, etc.) _____________________________
Patient Signature ____________________________ Date ____________________________
75 PROSPECT STREET, STE. 115, HUNTINGTON, N.Y. 11743
WWW.THESKINCLINICONLINE.COM | (631) 456-2075
Microdermabrasion Post Treatment Care
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Sunscreen (SPF 15 minimum) should be applied daily for 5 days post treatment
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No facial waxing, exfoliating products, glycolic, or Retin-A type products should be used
for 2-4 days following treatment
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You may experience temporary tightness, redness, or slight swelling which usually
dissipates within 24 hours depending upon individual skin sensitivity
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You may experience mild flaking over the next 3-4 days
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It is recommended that you only use a recovery cream following by sunscreen for the
next 3-5 days
75 PROSPECT STREET, STE. 115, HUNTINGTON, N.Y. 11743
WWW.THESKINCLINICONLINE.COM | (631) 456-2075