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COSMED LASER SPA 

MICRODERMABRATION 

I do understand the cancellations and rescheduling policy and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time.

I do understand that taxes and gratuities are not included in any service I purchased. It is common practice to tip 15-20 % of the original service price. Please feel free to extend a gratuity as a result of your experience. Gratuities are accepted in the form of cash or credit card.


 

(Please read carefully)

Please be aware that you are not a candidate for Microdermabrasion if you have and of the following conditions:

* Undiagnosed lesions

* Recent herpes outbreaks

* Warts

* Active weeping acne

* Active Rosacea

* Auto-immune system disorders

* Epilepsy

* Pregnant

The Microdermabrasion Treatment you will receive is a procedure designed to exfoliate or remove the outer layers of the skin. It is used to exfoliate and remove dead cells from the outer most layer of the skin. 


 

Your skin may be red or have a wind burned or sunburned look for a few days. Most side effects are temporary and generally subside within 72 hours. Possible (not probable) side effects include, and are not limited to, slight redness, extreme redness, swelling, bruising, stinging, tenderness, dry or flaking skin and lightening or darkening of the skin. In addition, side effects could include slight blood potting which may appear with deeper treatment levels. Healing may take several days or longer. 


 

Your participation in your skin care treatments will determine the outcome. It is important that you strictly adhere to your home care products that your esthetician had recommended. Keep the area clean and dry. Do not apply ordinary make-up for at least 3-14 hours after the treatment.

*No guarantee is expressed or implied as to the precise results

*During the procedure if you feel any discomfort you must notify the esthetician immediately so the pressure can be turned down on the machine. 


 

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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