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Microsoft word - microdermabrasion consent

CONSENT TO MICRODERMABRASION TREATMENT
PLEASE READ THE FOLLOWING INFORMATION AND ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT ALL PROVISIONS BY SIGNING BELOW I, __________________________________ , acknowledge and agree to hold Alamo Hills Advanced Aesthetic & Laser Center and any of its employees harmless against any and all liability and claims for any injuries or any other occurrence of events directly caused by active negligence of Alamo Hills Advanced Aesthetic & Laser Center or any of its employees. • The nature and purpose of the treatment has been explained to me, and any questions I have regarding this procedure have been explained to my satisfaction. • I understand that my skin care professional can discover other, or different conditions that may require additional or different procedures than those planned. If my skin care professional discovers additional conditions, I will be referred to an appropriate medical care provider. • 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 improvement 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 or unattractive scarring, or recurrence of the original condition. • I have been informed that there are risks such as loss of blood and infection that are attendant to the performance of any exfoliating procedure. • I understand that with any treatment certain risks are involved and that any complications or side effect from known or unknown causes could occur. I freely assume these risks. • Possible side effects include, but are not limited to: mild redness, extreme redness, bruising, local swelling, stinging, tenderness, dry skin, flaking, lightening or darkening of the skin, infections, pimples, bumpy appearance, and cold sores. Most side effects are temporary and generally • If I am prone to herpetic outbreaks, I have been advised to see my physician about a prescription for Acyclovir, Zovirax, or to take supplement of L-Lysine, Beta-Carotene and Folic Acid daily. • I have been advised to discontinue all AHA’s Glycolic, Retin-A, Renova, or any exfoliating products for up to 72 hours post-procedure. I understand that I must use hydrating and soothing antioxidants for healing, and ice for swel ing and inflammation reduction. Also, I understand there should be no sun or tanning bed exposure for 72 hours and the use of an SPF-30 at all times is advised. • I have been advised to avoid collagen injections for up to 10-14 days before and up to 7 days after any microdermabrasion treatment. I agree to these restrictions. • I have been advised of alternative methods available for my treatment, which include acid peels • I acknowledge my obligation to follow the written and spoken instructions covering my pre and • I understand that multiple treatments may be required. The cost of these was disclosed prior to the Alamo Hills Advanced Aesthetics & Laser Center 2876 Sycamore Dr., Suite 101 Simi Valley, CA 93065 CONSENT TO MICRODERMABRASION TREATMENT
I agree to all safety precautions and home skin care program as recommended by my clinician. I am over 18 years of age or I have parental consent co-signed below. I will call to inform my clinician of any complications or concerns as soon as they occur. I have read the contents of this consent form careful y and agree to receive the treatments or series of treatments outlined. 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 ful disclosure and supersedes any previous verbal or written disclosures. _______________________________________ ___________________________________ _________________ Patient Signature
Print Name


_______________________________________ ___________________________________ _________________
Witness Signature
Print Name
Alamo Hills Advanced Aesthetics & Laser Center 2876 Sycamore Dr., Suite 101 Simi Valley, CA 93065

Source: http://www.alamohillslaser.com/forms/Microdermabrasion_Consent.pdf

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