Vibradermabrasion Consent Form Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  My signature below constitutes acknowledgement that:

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  I (patient name)

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  consent to and authorize members of (clinic name)

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  to perform one of the following procedures and related services on me.

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  Vibradermabrasion

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  Microdermabrasion

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  Jet Peel

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  Acid Peel

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  Chemical Peel

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  Procedure elected is:

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  Body Area:

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  Those procedures involve the use of a different modalities to remove the top layers of the skin.

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  regarding treatment have been answered to my satisfaction.

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  and unknown causes and I freely assume these risks.

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  provided in this form.

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  I agree to adhere to all safety precautions and regulations during the skin treatment.

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  hours, use gentle cleanser only, acid washer (if desired) may be resumed 48 hours after treatment.

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  Patient Signature:

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  Date:

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  Parent/Legal Guardian:

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  Date:

• ...and More!