Microdermabrasion Consent Form

New Client Appointment Checklist

Complete and submit form below

Please arrive at least 15 minutes early for your first appointment.

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These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

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Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

New Client Form

CLIENT INFORMATION:

Name: *

Today's Date: *

Cell Phone Number: *

Home Phone Number:

Email: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate: *

Age: *

Gender: *

Are you currently a client of The Well of Life Center? *

If yes, who is your Clinician?

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

Client Consent

I hereby request and authorize Well Spa and its Skincare Specialists to treat me for the purpose of attempting to improve my appearance.
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.
I acknowledge that no guarantee has been given to me as to the number of months/years that my results will last.
I acknowledge that no guarantee has been given to me as to the amount of improvement expected following treatment.
I acknowledge that no guarantee has been given to me as to the painlessness of the procedure.
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 Microdermabrasion may cause a flare-up of the Herpes Simplex virus.
I have been advised to avoid or discontinue the following treatments for seven (7) 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.
I have been advised that a period of at least five (5) 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.
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.
I understand that I must apply a hypoallergenic, hydrating, anti-oxidant topical preparation to encourage epidermal regeneration, for at least seven (7) days post procedure.
I have been advised that a broad spectrum sunscreen must be used from the first date of my treatment and continued daily thereafter.
The following conditions (including, but not limited to those) listed below are not treatable with Microdermabrasion: impetigo, inflamed eczema, herpes simplex, severely distended capillaries, dermatitis, questionable lesions, and sunburn.
Possible side-effects to treatments are: local swelling, stinging, tenderness, flaking, peeling, lightening or darkening of 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.
I certify that all information provided is true and accurate. I agree to follow the protocol outlines above. I agree to hold harmless Well 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. Having been adequately informed, the patient will in no case be entitled to a refund.

Click below to agree:

I agree to apply a broad spectrum sunscreen daily.

Electronic Signature: *

Sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Microdermabrasion Client Consent.

Pre- and Post Care Guide and Liability Release Form and Agreement and Release of Liability: *

Please click HERE to read our Pre- and Post Care Guide and Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Liability Release Form and Agreement and Release of Liability as well as understand proper pre- and post-care for microdermabrasion.

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