Microdermabrasion Consultation and Consent Form

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Client Name: *

Date: *

Date of Birth: *

Email: *

Address: *

Postcode: *

Home Phone:

Mobile: *

How would you like us to contact you? *

Text Email

Do you suffer from or are taking any of the following:

• Oral Anti-coagulants *

Yes No

• Roaccutane *

Yes No

• Active, uncontrolled or brittle diabetes *

Yes No

• Active Viral lesions, Herpes Simplex, Shingles *

Yes No

• Eczema or Seborrheic Dermatitis *

Yes No

• Rosacea *

Yes No

• Skin cancer and auto immune disorders *

Yes No

• Lupus *

Yes No

• Allergies to Aspirin/Latex/Nuts etc *

Yes No

• Visible, broken blood vessels *

Yes No

• Cancer, AIDS, HIV or any autoimmune disorder *

Yes No

• Sun Erythema *

Yes No

• Warts, Moles and Skin Tags *

Yes No

• Lipoma *

Yes No

• Hemangioma *

Yes No

Any other medical condition:

Consent

Prior to receiving this treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

I understand there may be some degree of minor discomfort, i.e., scratchiness, itchiness.

I understand that to achieve maximum results, I will need several ongoing treatments and use a consulted regimen to enhance results.

I will follow the homecare regimen specifically consulted for me and will only change the regimen with prior advise from my physician.

I understand that the possibility of irritation and redness exists and that I should notify my physician immediately if this occurs.

Do you consent to us taking before & after photographs? *

Yes No

Do you consent to us using these for demonstration purposes? *

Yes No

I agree to the above and am happy to proceed with treatment.

I will follow all prescribed directions regarding post microdermabrasion care.

SIGNATURE: *

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Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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