Microdermabrasion Consultation/Consent Form | Aesthetics Forms Portal

Microdermabrasion Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Do any of the following apply to you? Please tick all that apply.

Do you have any other medical conditions? *

Please provide detail: *

Are you currently, or possibly may be, pregnant or breastfeeding? *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

In the last 4 weeks have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin? *

Please specify treatment type and date: *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

What are your skin concerns? *

What are your goals and expectations of the treatment? *

Treatment Information

Microdermabrasion is a minimally invasive procedure used to renew overall skin tone and texture. It can help improve the appearance of skin affected by sun exposure, wrinkles, acne, and other conditions.

The procedure uses a special applicator with an abrasive surface to gently sand away the thick outer layer of the skin to rejuvenate it.

Potential Side Effects

Common side effects of microdermabrasion include mild tenderness, swelling, and redness. These generally go away within a few hours after treatment.

You may use moisturizer to minimize dry and flaky skin. Minor bruising may also occur. This is mostly caused by the suction process during the treatment.

Aftercare

There is little to no downtime after microdermabrasion. You should be able to resume your daily activities immediately.

Aftercare Advice:

Keep your skin hydrated and use gentle skin care products.
Avoid using topical acne medications for at least one day after treatment.
It’s extremely important to protect your skin with sunscreen. Your skin can be more sensitive to the sun in the few weeks after the treatment.

You can expect to see noticeable results immediately after the procedure. The number of microdermabrasion sessions needed will depend on the severity of your skin concerns as well as your expectations.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Microdermabrasion treatment(s) to be carried out.

Client Signature: *

Tap or click on the signature above to sign