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Microdermabrasion Consent Form 

1. I hereby request and authorize Sage Wellness Spa and its Skincare Specialists to treat me for the purpose of attempting to improve my appearance.


2. The effect and nature to be given has been explained to me. I acknowledge that the goal of the treatments is to induce improvements in my skin, but individual results will vary. 


3. I acknowledge that no guarantee has been given to me as to the number of months/years that my results will last. 


4. I acknowledge that no guarantee has been given to me as to the amount of improvement expected following treatment. 


5. I acknowledge that no guarantee has been given to me as to the painlessness of the procedure. 


6. I have been advised to see my physician regarding a preventative ant-viral prescription if I am prone to Hepatitis outbreaks (cold sores/fever blisters). I understand that acid treatments and/or microdermabrasion may cause a flare-up of the Herpes Simplex virus.


7. I have been advised to avoid or discontinue the following treatments for five (5) days prior to my treatment.

  • BOTOX® injections
  • Collagen Injections
  • Retin-A, Renova, and all retinol products
  • Glycolic acid products
  • All alpha and beta hydroxy acid products


8. I have been advised that a period of at least three (3) days must elapse before I can resume the use of the following products.

  • BOTOX® injections
  • Collagen Injections
  • Retin-A, Renova, and all retinol products
  • Glycolic acid products
  • All alpha and beta hydroxy acid products


9. I acknowledge that I have not taken Accutane in the past 12 months. I further agree to not take Accutane during my treatment program and for six (6 ) months after ending my treatments. 


10. I understand that I must apply a hypo-allergenic, hydrating, ant-oxidant topical preparation to encourage epidermal regeneration, for at least seven (7) days post procedure. 


11. I have been advised that a broad spectrum sunscreen must be used from the first day of my treatment and continued daily thereafter. 




12. Clients who should not be treated I have been advised the following conditions are recognized as contraindications for microdermabrasion treatment and must be disclosed prior to treatment: Active infection of any type, such as Herpex Simplex virus or flat warts, Active acne, Excessively sensitive skin, Recent use of topical agents such as glycolic acids, alphahydroxy acids and Retin-A, Any recent chemical peel procedure, Uncontrolled diabetes, Eczema, dermatitis, Skin cancer, Vascular lesions, Oral blood thinner medications, Inflammatory rosacea, Tattoos (not effective), Pregnancy, Use of Acutane within the last year, Family history of hypertrophic scarring or keloid formation, Telangiectasia/erythema may be worsened or brought out by skin exfoliation, Allergy to salicylates (i.e.,aspirin), Chemotherapy or radiation therapy, impetigo, Inflamed eczema, dermatitis, questionabe lesions, and sunburn.

13. Possible side-effects to treatment are: local swelling, stinging, tenderness, flaking, peeling, lightening or darkening of the skin and/or mild to moderate redness. It is possible that one or more of these side effects any last for two (2) to seven (7) days post procedure. However, most subside within 24 hours. 


14. I certify that all information provided is true and accurate. I agree to follow the protocol outlined above. I agree to hold harmless Sage Wellness Spa and its Estihician for any adverse reactions due to omitted information and or misinformation on the Health questionnaire and/or from actions which deviate from pre and post care procedures. 


POST-TREATMENT/HOME CARE

It is crucial to the health of your skin and the success of your treatment that these guidelines be followed:

  • Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided
  • Direct sunlight exposure is to be completely avoided immediately following the treatment for at least 1 week (including any strong UV light exposure and tanning beds). If some sun exposure cannot be avoided, first apply sunscreen with SPF of 30 or greater. Although sunscreen should be a part of your daily skin care, for a minimum of two weeks, a sunscreen with at least an SPF 20 must be applied.
  • Apply a light moisturizer as often as needed to relieve dryness and tightness.
  • In the event that you may have additional questions or concerns regarding your treatment or suggested home product / post-treatment care, you must consult your esthetician immediately. 

I understand that the Chemical Peel treatment is not an exact science and the degree of improvement is variable. 


 

I understand that occasionally there is no visible improvement and another form of treatment may be required. 


I do not have any of the conditions described in the “Clients Who Should Not Be Treated” section. 


CLIENT CONSENT - MICRODERMABRASION

I have read the above information and initialed each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my skin therapist. I give permission to my therapist to perform the microdermabrastion procedure we have discussed and will hold her and Sage Wellness Spa harmless from any liability that may result from this treatment. I understand my therapist will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I have given an accurate account of any over the counter or prescription medications that I use regularly and I am not presently using isotretinoin (Accutane). I have not had any facial surgical procedures or other chemical peels or skin treatments that I have not disclosed to my therapist. I am not ingesting or using topically any other over the counter product or prescription medication/agent that has not been disclosed to my therapist. I am not presently pregnant or lactating and I am over the age of 18. I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin. I have not recently waxed or used depilatory (such as Nair) on the area to be treated. I do not have history of keloidal scarring ,excessive telangiectasia, rosacea, bacterial skin infections, fungal infections, viral infections, open lesions or rashes, active acne, any auto immune disease, or any other existing condition that may interfere with the positive outcome of this treatment.

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my therapist.

My expectations are realistic and I understand that the results are not guarantueed.

I agree that I am willing to follow recommendations by my esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by esthetician and I acknowledge that I have been informed of the possible negative reactions and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have additoinal questions or concerns regarding my treatment or suggested home products/post-treatment care, I will consult my therapist immediately. 

I certify that I have read, and fully understand this Client Informed Consent Form. I understand the potential risks, complications and benefits and have chosen to proceed with the treatment. I have been given the opportunity to ask questions and my questions have been answered to my satisfaction. 

    

April 26, 2024

First Client's Name

First Name*

Last Name*
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 Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Please read and sign below

I voluntarily request that Essentials Massage & Facial Spa (and such skincare professional she or he may deem necessary) to perform the Microdermabrasion procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin.

I understand that my skincare professional can discover other, or different conditions that may require additional or different procedures than those planned. If my skincare professional discovers such other or different conditions I will be referred to appropriate medical care provider. 

I acknowledge that, while the goal of such a procedure is the removal of damaged skin, the realistic results average 50-75% improvement. I acknowledge that the practice of cosmetology is not an exact science and that no specific guarantees can or have been made concerning the expected result. Some clients are improved and in others no appreciable improvements is noticed. 

I also realize that the following risks and hazards may occur in connection with the particular procedure; worsening or unsatisfactory appearance, creation of additional problems such as: poor healing or skin loss, nerve damage, painful unattractive scarring, or recurrence or the original condition. 

I have been advised that I must use sunscreen of SPF 20 or greater at all times throughout the course of treatment. 

I have been informed that there are risks such as loss of blood and infection that are attendant to the performance of any exfoliation procedure. 

I have been advised of alternative methods available for my treatment, which includes acid peels and laser skin resurfacing. 

I acknowledge my obligation to follow the written and spoken instructions covering my pre and post treatment skincare regimen.

I understand that multiple treatments may be required. The cost of these was disclosed prior to the first treatment. 

I have received a thorough explanation of my pre-exfoliation and post-exfoliation instructions. I understand these instructions and have received copies for reference. I understand that should I have additional questions, I should not hesitate to call. 

I certify that I have read the above consent and I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. I hereby consent to the Microdermabrasion procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures. 

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*
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 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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