Microdermabrasion Intake Form

 
Name *
Name
Address *
Address
Phone *
Phone
Are you a student?
Have you ever experienced any of the following?
Do you smoke?
Do you wear contact lenses? *
Are you under the care of a physician or dermatologist?
Any dermal injections/fillers within the last 6 months?
Are you using any products that contain: Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid,AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription skin products? *
Have you used any of the products listed above in the past 3 months? *
Have you ever had any of the following treatments? *
Have you ever had any allergic reactions to any skin products? *
Do you wear sunscreen daily?
Are you currently or trying to become pregnant?
Are you currently lactating?
Any recent changes to/from your contraceptive treatment?
What is Microdermabrasion?
Microdermabrasion uses an adjustable applicator head that removes dead surface skin cells and initiate cellular turnover at the dermis and epidermis levels in a safe, controlled manner. This approach respects the integrity of the skin and promotes even healing. Maintaining even cellular growth on the surface aids in the youthfulness of the skin’s appearance. Microdermabrasion has been used to treat aging and sun-damaged skin, some types of acne and acne scarring, altered pigmentation, fine lines and wrinkles, and stretch marks. Results may include improved skin tone, fewer breakouts, diminished appearance of scars, even skin color, refined skin pores, renewed elasticity, and a healthy glow. Elm City Wellness estheticians take every precaution to ensure that your skin is well hydrated and calm prior to leaving each session. However, you may experience excessive dryness or even some peeling between sessions, which may or may not be normal. Always check with us if you have concerns after treatment. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 -3 hours. After your treatment, sun block must be worn for the first 48 hours after your appointment and you must keep your skin well hydrated. You are making an investment in your skin, therefore, it is to your benefit to continue to protect it long after your facial is completed. Sunscreen with an SPF of 30 or higher should be worn daily.
Contraindications:
Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for microdermabrasion treatment and must be disclosed prior to treatment. Please check yes or no for each contraindication listed below.
Please mark any that apply to you: *
Please read and check each section: *
Prior to this treatment I have been candid in revealing any condition that may have a bearing on this procedure, such as pregnancy, recent facial peels, surgery, allergies, tendencies to cold sores, fever blisters and use of Accutane 4 weeks prior. Retinols and AHA’s have not been used 3 days prior to this treatment and will not be used within 3 days after treatment. Use of depilatories, waxing, electrolysis, laser hair removal, collagen injections stopped during the treatments and I will wait at least seven days after conclusion.
*
I understand that no specific results are guaranteed with this procedure.
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I understand that pinkish and redness to the skin is very common and may last several hours and could persist for a few days. I understand that irritation may exist and I understand I should notify my skin care professional if irritation persists. Avoid any type of UVA/UVB exposure for at least 48 hours following this procedure. My skin will be delicate during this time, so I will and protect it from the sun by using a sunscreen an SPF 30 or higher on a daily basis. I will also keep the skin well moisturized.
*
Acne Clients: I understand that I may experience a slight acne flare up, and that my acne condition may temporarily look worse for a few days after a microdermabrasion treatment. I agree to all of the above to have this treatment performed on me today and for all subsequent treatments. I do not hold my skin care professional responsible for any of my conditions that are present but not disclosed at the time of this skin care procedure. I will notify my skin care professional of any changes to my medical history or change in my skin care products. I will follow all prescribed directions post treatment.
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If I am unable to keep an appointment, I understand that 24-hour notice is required; otherwise I will be charged the cost of the session by whatever payment method is on file. If I decline to have payment on file, I am required to pay the 50% deposit each time I book an appointment.
Client Consent: I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential. The treatments I receive here are voluntary and I release this institution and/or skin care professional from any liability and assume full responsibility thereof. *
Client Consent: I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential. The treatments I receive here are voluntary and I release this institution and/or skin care professional from any liability and assume full responsibility thereof.