Microdermabrasion Informed Consent


Hidden Beauty Within

Ultrasound Microdermabrasion Informed Consent

This form is designed to give you the information you will need to make an informed choice as to whether or not to undergo microdermabrasion. If you have any questions, please do not hesitate to ask. Although microdermabrasion is effective in most cases, no guarantee can be made that a specific client will benefit from the treatment.

Ultrasound has been used for cosmetic purposes since the early 1980’s. Because of its wide therapeutic use and the great results, the ultrasonic instrument is a natural for use in skincare treatments. Ultrasonic sound waves act on the body in the following way: they stimulate cells. It improves local blood and lymph circulation, and increases the penetration of skin enhancing products. Small doses of ultrasound can promote the synthesis of protein inside the cells, help to regenerate wounded tissues and promote the synthesis of fiber cells in the body.

The sound waves are also used to push in vital nutrients. This two step treatment causes the skin to receive product by first exfoliating and then deep penetration of nutrients, stimulating the skins natural collagen fibers to help re-build the tissues.

What are the contraindications of the ultrasound microdermabrasion treatment?



This treatment cannot be performed on anyone with a pacemaker or electrical implant

This treatment cannot be performed on anyone with a heart condition

Further Considerations for Consent

A. I acknowledge that no guarantee has been given to me as the condition of the complexion, skin pore size, wrinkle reduction, or the amount or percentage of improvement expected following the treatment.

B. I acknowledge that for many conditions, more than one microdermabrasion treatment may be required in certain areas to achieve the desired result.

C. I acknowledge that an enzyme will be applied to my skin prior to the ultrasonic treatment

D. I acknowledge that I have not waxed my face or used Retin-A, Renova, Differin or AHAs for at least 7 days.

E. I acknowledge that I have not had a collagen or Botox injection for at least 14 days.

F. I acknowledge that I have not used Accutane for the last 6 months.

G. I acknowledge that I do not have a pacemaker, electrical implants or a heart condition.

H. I acknowledge that it is imperative to wear a UVA/UVB sunblock with an SPF of 30 or greater everyday and to avoid direct sunlight and tanning beds.


By signing below, I acknowledge that I have read the foregoing informed consent regarding microdermabrasion, and I feel

I have been adequately informed regarding the associated risks. I hereby give consent to a microdermabrasion treatment to be performed by: Diane French, Licensed Esthetician.

Client Name Printed:________________________________________________________________________________

Client Name Signature:__________________________________________ Date:_______________________________

Esthetician Signature:____________________________________________Date:_______________________________