Microdermabrasion, Chemical Peel, Dermaplaning Consent Form Name* I hereby request and authorize Dr. K’s Med Spa and its Skincare Specialists to treat me for the purpose of attempting to improve my appearance. 1. 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. 2. I acknowledge that no guarantee has been given to me as to the number of months/years that my results will last. 3. I acknowledge that no guarantee has been given to me as to the amount of improvement expected following treatment. 4. I acknowledge that no guarantee has been given to me as to the painlessness of the procedure. 5. I have been advised to see my physician regarding a preventative anti-viral prescription if I am prone to Herpetic outbreaks (cold sores/fever blisters). I understand that acid treatments and/or microdermabrasion may cause a flare-up of the Herpes Simplex virus. 6. 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 retinoic products Glycolic acid products, All alpha and beta hydroxy acid products. 7. 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 retinoic products, Glycolic acid products, All alpha and beta hydroxy acid products. 8. 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 and understand that I must apply a hypoallergenic, hydrating, anti-oxidant topical preparation to encourage epidermal regeneration, for at least seven (7) days post procedure. 9. I have been advised that a broad spectrum sunscreen must be used from the first date of my treatment and continued daily thereafter. I agree to apply a broad spectrum sunscreen daily. 10. The following conditions (including, but not limited to those) listed below are not treatable with microdermabrasion and/or acid peeling solutions: impetigo, inflamed eczema, herpes simplex, severely distended capillaries, dermatitis, questionable lesions, and sunburn. 11. Possible side-effects to treatment are: local swelling, stinging, tenderness, flaking, peeling, lightening or darkening or the skin and/or mild to moderate redness. It is possible that one or more of these side effects may last for two (2) to seven (7) days post procedure. However, most subside within 24 hours. 12. I certify that all information provided is true and accurate. I agree to follow the protocol outlined above. I agree to hold harmless Dr. Ks Med Spa and its Skincare Specialists 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. Date MM slash DD slash YYYY Untitled* I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure. Staff signature ___________________ Patient signature ___________________ CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
