DERMAMED MEGAPEEL EX SILVER SERIES, Instructional Manual

Page: 39 / 51

39
MegaPeel EX
®
Microdermabrasion Treatment
CONSENT FORM
Prior to receiving this treatment, I have been candid in revealing any condition that may have a bearing
on this procedure, such as, pregnancy, recent facial peels or surgery, allergies, tendencies to cold sores
and fever blisters, use of Retin-A, Accutane or Hormones.
I understand there may be some degree of minor discomfort, i.e., scratchiness, itchiness.
I understand there are no guarantees to this procedure.
I understand that to achieve maximum results, I will need several ongoing treatments and will need to
use a daily product over a period of time.
I understand that the possibility of irritation and redness exists and that I should notify my skin care pro-
fessional when irritation persists.
I will follow the home care program specifically designed for me without changing or adding any prod-
ucts without consulting with my skin care professional.
I have read the enclosed consultation and understand the contents.
I agree to all of the above to have this treatment performed on me and will follow all prescribed directions
regarding post peel care.
PRINT NAME: _______________________________________
ADDRESS: _______________________________________
_______________________________________
_______________________________________
SIGNATURE: _____________________________________________________ DATE: _______________