Aesthetic Florida
MICRODERMABRASION, DERMAFILE AND/OR CHEMICAL PEEL
PATIENT INFORMATION / MEDICAL HISTORY
Full Name:
Date of Birth:
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Address:
Home #:
Cell #:
Email:
How did you hear about us?
IT IS THE CLIENT’S RESPONSIBILITY TO NOTIFY [NAME OF COMPANY] IF YOUR PHONE NUMBER FOR
CONFIRMATIONS HAS CHANGED.
Check #
Cash
Credit
Payment in full _____________ Down Payment ______________ Balance: ___________ Due on:
Please Circle
Pregnant
YES / NO
Diabetes
YES / NO
Herpes/ Cold Sores
YES / NO
Histamine (Hives)
YES / NO
Epilepsy
YES / NO
Keloids
YES / NO
Other:_________________________________
Smoking
History of Acne
Any Blood Disease
Skin Cancer
Allergies
Present Illnesses
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/ 2014
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
One week prior to treatment, did you discontinue using all alpha hydroxy acid products (those containing glycolic or lactic acid),
salicylic acid products, retinoids (Retin A, Renova, Differin and Tazorac) and other topical acne medications such as benzoyl
peroxide.
YES / NO
Six to twelve months prior to treatment, did you discontinue using Accutane?
YES / NO
Present Medications:
(Aspirin, Antibiotics, Cortisone, Photosensitive such as Hormones, St. John’s Wort, Oral Contraceptives, Depression Medication or MoodAltering Drugs)
Skin:
Light / Medium / Tan / Olive / Brown / Dark brown
Tanning/Sun Exposure:
Daily/ Weekly/ Monthly /Yearly
Previous Treatments:
Tweezing / Waxing / Shaving / Bleaching / Electrolysis / Laser
Hair Type/Color:
Course / Average/ Fine / Black / Brown/ Light Br / Blonde / Red / Gray / White
Race/Ethnicity
Caucasian / Hispanic / Mediterranean / Indian / African / Other:
I agree that the information listed above has been reviewed and presented with my clear understanding of what this procedure involves. I,
the undersigned, declare that I have answered all of the above questions to the best of my ability and knowledge. I will not hold any CCE,
CME, Physician, Student, or any member/staff responsible for any errors or omissions that I may have made in the completion of this
form. With full and clear understanding, by signing below I release the technician and/or student from liability associated with these
procedures. By signing below, I understand that treatments may be performed by students, supervised by qualified instructors, for the
purpose of internship/hands-on practice.
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Aesthetic Florida
MICRODERMABRASION, DERMAFILE AND/OR CHEMICAL PEEL
PATIENT INFORMATION / MEDICAL HISTORY
PATIENT CONSENT
The purpose of these procedures is to rejuvenate sun-damaged skin, ease age spots, improve the look of fine lines and wrinkles, help
makeup look smoother, give acne treatment the advantage and improve acne scars, and shrink pores. In order to ensure maximum results, it
is necessary to follow the recommended treatment schedule. The total number of treatments will vary between individuals. On occasion,
there are patients that do not respond to treatments. I understand the nature, goals, limitations and possible complications of this
procedure and have discussed alternative forms of treatment. I have had the opportunity to ask questions about the procedure, as well as
any limitations, complications and/or side effects.
I have read, agree to, and understand the following:
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The goal of any treatment, as in any cosmetic procedure, is improvement, not perfection, and results may not be perfect due to
any genetic, hormonal, nutritional, or topical applications interference or an impact of unpredictable reactions.
It is important to follow all post-treatment instructions carefully. Compliance is crucial for healing and prevention of scarring.
Short-term effects may include discomfort at treatment site, redness, mild burning, and temporary flaking or peeling of skin. (This
may last a few days). Hyper-pigmentation (darkening) and Hypo-pigmentation (lightening) have also been noted after treatment.
These conditions usually resolve within 1-4 months, but permanent color change is a rare risk. Avoiding sun exposure before
and after treatment reduces the risk of color change.
Individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus
infections. Bacterial, fungal and viral infections can occur. Herpes simplex (viral infections) around the mouth can occur
following a treatment. Should any type of skin infection occur, check with your physician for proper treatment.
Allergic Reactions: In rare cases, allergies to tape, preservatives used in cosmetics, topical preparations, etc. have been reported.
Systemic reactions (which are more serious) may result from prescription medicines.
Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation.
Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make
every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.
Do not accept advice from anyone not directly responsible for your post care. Suggestions from friends may be sincere, but are
often not helpful or even innocently harmful.
ACKNOWLEDGEMENT
I have read and understand all of the above. I have asked any and all questions that I have regarding the procedure of microdermabrasion,
dermafile and/or chemical peel, pre-treatment and post-treatment. I was given written instructions for post-treatment care at home. I
understand completely and will take full responsibility for post-treatment care. All of the treatment fees have been discussed with me and I
understand them completely
My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release
all related staff from all liabilities associated with the above-indicated procedure. By signing this form, I am giving Aesthetic Florida
permission to treat me, and I understand all symptoms and side effects that may occur during or after treatments, thereby releasing
Aesthetic Florida of all liability regarding these issues.
We provide each client with full consultation, before treatment, and information of pre and post care necessary to achieve the best results
possible.
All clients MUST sign this Consent Form indicating that they have read all the pre- and post-treatment instructions, which are also
discussed during consultation. The consent form is an agreement with the client that he/she is agreeing to be treated and that the client fully
understands all pre- and post-treatment instructions as well as possible symptoms and/or side effects and skin reactions that may occur due
to treatment.
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Aesthetic Florida
MICRODERMABRASION, DERMAFILE AND/OR CHEMICAL PEEL
PATIENT INFORMATION / MEDICAL HISTORY
I understand that only the treating licensed Esthetician can decide if treatment is NOT appropriate for the following reasons:
 Sun exposure
 Change of pigmentation
 Medications
 Extreme sensitivity or allergic reactions in the treated area
If I mislead the licensed Esthetician for any of the reasons mentioned above, by signing below I fully understand and take responsibility for
the post-treatment consequences.
Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to
notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.
Should you have any concerns or questions, please do not hesitate to call our office. Our main goal is client satisfaction. That is why it is
VERY important to educate our client so they will fully understand the procedures of skin resurfacing and have trust, confidence and
cooperation in their decision.
ARBITRATION AGREEMENT
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I understand and agree that any dispute concerning medical malpractice will be determined by arbitration; the term medical
malpractice interpreted broadly and shall include any and all claims in tort, contract, lack of informed consent or other legal theories
which in any way pertain to claims or unnecessary, unauthorized, improper, negligent, or incompetent rendering of medical treatment.
I understand that I am giving up my rights to bring a lawsuit or to resort to any court process except as Florida Law provides for
judicial review of arbitration proceedings. By signing this Agreement, I agree to resolve all disputes by arbitration rather than through
the court.
I understand and agree that this Arbitration Agreement binds me and anyone else who may have a right to assert a claim on my behalf
or make a claim as a result of injury to me. I also understand that if I sign this Agreement on behalf of someone else, I am binding to
this Agreement.
I understand and agree that this Agreement relates to claims against the physician/technician and all consenting substitute
physicians/technicians, their partnerships, professional corporations, employees, heirs, assigns or successors in interest.
I understand that this is a legal document and I have been advised of my rights to obtain legal counsel before signing this Agreement.
By signing I fully understand this Agreement contains all the terms and conditions relating to Arbitration.
I understand that I am forfeiting my rights to any trial. The damages awardable at arbitration are limited to those available under
Florida law.
Within fifteen (15) days after a party to this agreement has given written notice to the other of demand for arbitration of a dispute or
controversy, the parties to the dispute or controversy shall each appoint an arbitrator and give notice of such appointment to the other.
Within a reasonable time after such notices have been given the two arbitrators so selected shall select a neutral arbitrator and give
notice of the selection thereof to the parties. The arbitrators shall hold a hearing within a reasonable time from the date of notice of
selection of the neutral arbitrator.
Expenses of the arbitration shall be shared equally by the parties to this agreement.
Except as herein provided, the arbitration shall be conducted and governed by the provisions of the Florida Arbitration Code, Florida
Statues s. 682.01 et. seq.
Any party to this agreement who refuses to go forward with arbitration hereby acknowledges that the arbitrator will go forward with
the arbitration hearing and render a binding decision without the participation of the party opposing arbitration or despite its absence at
the arbitration hearing.
I understand that my request for arbitration concerning alleged medical malpractice must be made within the statute of limitations for
filing any claim of malpractice as provided by Florida law and failure to seek arbitration within the applicable statute of limitations
will forever prevent the submission of any claims.
The patient has the right to rescind this agreement by written notice to the provider of medical services within three (3) days after the
agreement has been signed and executed. The patient may rescind by merely writing “cancelled” on the face of one of his/her copies
of this agreement, signing his name under such word, and mailing, by certified mail, return receipt requested, such copy to the
provider of medical services with such three (3) day period.
With respect to any dispute or controversy that is made subject to arbitration under the terms of this agreement, no suit at law or in
equity based on such dispute or controversy shall be instituted by either party, except to enforce the award of the arbitrators.
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Aesthetic Florida
MICRODERMABRASION, DERMAFILE AND/OR CHEMICAL PEEL
PATIENT INFORMATION / MEDICAL HISTORY
Initial Please
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I have provided my past and current medical history and medications.
___________
I consent to the taking of photographs during the course of my laser therapy for healthcare records.
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I consent to using my photographs for medical education and/or marketing purposes. My name will not be used to
identify these photographs.
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I am not pregnant.
___________
I have been given the opportunity to ask questions about the procedure. My questions have been answered and I
understand the information given to me.
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Contraindications to the performance of this procedure have been discussed in detail with me.
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I recognize that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to
me concerning the results of such procedures.
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I have read and understood all information presented to me before signing this consent form.
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I hereby release all related staff from all liabilities associated with the above-indicated procedure.
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By signing this form, I am giving Aesthetic Florida permission to treat me, and I understand all symptoms and
side effects that may occur during or after treatments, thereby releasing Aesthetic Florida of all liability regarding these
issues.
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24 HOURS CANCELLATION POLICY Confirmation of your appointments is a courtesy call not an obligation. It is
the client’s full responsibility to keep track of his/her scheduled appointments. If client fails to notify of appointment
cancellation at least 24 hours in advance. For any credit card payments, a 10% surcharge and merchant fee will be
deducted in case of any refunds 14 (fourteen) days after original transaction.
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NO REFUND POLICY By signing this No Refund Policy, I am agreeing that any service(s), service package(s), gift
certificate(s), and/or retail product I purchase(s) at Aesthetic Florida is a final sale. I understand any and all
services(s), service package(s), gift certificate(s), and/or retail product(s) purchased will not be refunded or issued a
credit. I also understand that if I decide to cancel or postpone any service(s), service package(s), gift certificate(s),
and/or retail product(s), I will forfeit all monies paid; including any deposits and/or payments I have already paid.
I acknowledge being given a copy of this Agreement at the time it was signed.
Signature
Date
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/201
Date
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/201
Print Full Name
Skincare Specialist_____________________________
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Aesthetic Florida
MICRODERMABRASION, DERMAFILE AND/OR CHEMICAL PEEL
PATIENT INFORMATION / MEDICAL HISTORY
PRE-TREATMENT INSTRUCTIONS
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Two days prior to treatment, discontinue using all alpha hydroxy acid products (those containing glycolic or lactic acid), salicylic
acid products, retinoids (Retin A, Renova, Differin and Tazorac) and other topical acne medications such as benzoyl peroxide. If
in doubt about using any product, please discontinue it and discuss with the nurse at your appointment.
Men should not shave immediately before.
The following procedures should not be performed for a minimum of 7 days before microdermabrasion:
 Waxing
 Tweezing
 Electrolysis
 Laser treatments (any kind)
 Injections (Collagen & BOTOX)
 Chemical peels (any kind)
 Facials
If you have a history of herpes simplex virus (cold sores or fever blisters), in rare instances a reactivation of this condition could
occur after treatment. Please inform your nurse or physician so that an anti-viral medication can be prescribed before the
treatment.
POST-TREATMENT INSTRUCTIONS
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Cleanse and moisturize your skin twice daily.
Do not use any alpha hydroxy acid products (those containing glycolic or lactic acid), salicylic acid products, retinoids (Retin A,
Renova, Differin and Tazorac) and other topical acne medications such as benzoyl peroxide for 72 hours after the treatment.
Do not directly expose the treated area to the sun for at least 48 hours after the treatment. Use a sunscreen every day that blocks
both UVA and UVB rays, preferably one containing zinc or titanium dioxide which should not irritate the skin.
The following procedures should not be performed for a minimum of 7 days after microdermabrasion:
 Waxing
 Scrubs or exfoliants
 Electrolysis
 Tweezing
 Injections (Collagen & BOTOX)
 Laser treatments (any kind)
 Facials or masks
 Chemical peels (any kind)
If you do undergo these procedures after the 7 day waiting period, notify the appropriate person that you have had
microdermabrasion.
The following is a partial list of ingredients that you should avoid for 72 hours after microdermabrasion:
 Artificial color/fragrance
 Alpha hydroxy acids (including glycolic and lactic acid)
 SD Alcohol
 Lanolin
 Salicylic acid
 Benzoyl peroxide
 Hydroquinones (Alustra, Lustra AF, and Glyquin)
 Retinoids (Retin A, Renova, Differin and Tazorac)
 Propylene glycol
 Recommended products which will enhance your response to the treatment:
 DCL Non-Drying Cleansing Lotion (Blue) - gentle liquid cleanser. Use 1 to 2 times daily.
 DCL No Sting Chemical Free Sunblocking Cream - contains non-irritating sun protection ingredients for sensitive skin. Use
daily.
 DCL Post-Peel Recovery Cream - specially formulated to help moisturize the skin after treatments. Use 1 to 2 times daily as
a moisturizer.
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