Microdermabrasion Consent Form Name : * First Name Last Name Guardian's Name : (in case when the client is a minor) First Name Last Name Phone : * (###) ### #### Email : I hereby, agree to have a Microdermabrasion performed on my face. By signing this agreement, I consent to the Microdermabrasion treatment performed by a Brows on Fleek technician. I understand and have been informed that it uses an adjustable applicator head that removes dead surface skin cells and initiates cellular turnover at the dermis and epidermis levels in a safe controlled manner. I understand that a thorough skin analysis will be performed prior to the procedure, and if the procedure is not appropriate or contraindicated, an alternative treatment may be recommended instead. I understand that more sensitive skin may experience some redness, excessive dryness or even some peeling, and/or may cause superficial abrasions which may or may not be normal and may not appear until a couple days following the treatment. I agree that if I experience any of these conditions that I will contact the certified technician that performed this procedure and that it may be beneficial to contact a physician immediately at my own expense. I understand that desired outcome cannot be guaranteed as maximum results are highly dependent on age, cumulative sun exposure, health, lifestyle, genetic traits, general skin condition, and/or willingness to follow recommended protocols. I understand and agree to the after-care instructions provided by the technician. I realize and accept the consequences of failure to adhere to these instructions may cause injury to the skin and/or scarring. • SPF30+ must be always worn or at least 2 weeks after the treatment (should already be a part of daily skincare). • Direct sunlight exposure must be avoided immediately following the treatment (including UV light exposure). • Vigorous physical activity should be avoided until all redness has subsided. • Tanning beds should never be used. • Must cleanse the treated area with a post-treatment cleanser twice daily, followed by a serum or treatment cream, followed with SPF30+ sunscreen. I am aware that many changes may occur deeper within the skin overtime and I understand that I may or may not be informed of long-term age management programs to continue the maintenance of skin after completion of the treatment. I am informing the certified technician of the following conditions/ contraindications by marking with a check, agreeing to have the procedure be performed on me despite any risk: Active Acne Any recent chemical peel procedure Eczema or dermatitis Moles Pregnancy Scleroderma Sunburn Thick, dark facial hair Use of Accutane within the last year Any raised lesions Chemotherapy or Radiation Hemophilia Oral blood thinner medication Rosacea Skin Cancer Tattoos Uncontrolled diabetes Vascular Lesions Active infection of any type, such as herpes simplex or flat warts Family history of hypertrophic scarring or keloid formation Hormonal therapy that produces thick pigmentation Recent use of topical agents such as glycolic acids, alpha-hydroxy acids and Retin-A Telangiectasia/ erythema may be worsened or brought out by exfoliation Any known allergies (please specify) : Any medical and/or skin condition which would prohibit or compromise facial service (please specify) : This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified technician, and will hold the technician/s harmless from any liability that may result from this procedure. I read English and understand that this consent agreement is legal and binding. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above agreement clauses, and that I have had sufficient opportunity for discussion to have all my questions answered. I understand the procedure and accept the risks. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. I further agree that I will not hold Brows on Fleek or its affiliates or any of its employees responsible should there be any unfavorable outcome or result. Date * MM DD YYYY Thank you!
