Name(Required) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)I understand that microdermabrasion is a superficial mechanical abrasion to the skin.(Required) I understand that the mechanical abrasion is accomplished by using a crystal microdermabrasion machine that delivers a vacuum and uses a crystal tip that exfoliates the skin.(Required) I understand that one of the primary purposes of this procedure is to prepare the skin to accept and increase the absorption properties of active ingredient rejuvenation products and or chemicals.(Required) It has been explained to me that because microdermabrasion procedures provide a superficial abrasion to the skin, the results of a one-time treatment is similar to a deep cleansing or polishing of the skin. I understand that in order to see significant results, these treatments need to be done in a series and in combination with active ingredient skin care products.(Required) I acknowledge that immediately after my microdermabrasion procedure all treated areas may feel warm and appear sunburned and could feel wind burned. My skin may feel dry and sensitive for several days after the treatment.(Required) I understand that compliance with my after-care instructions will greatly affect my final result.(Required) Acne Patients: It has been explained to me 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.(Required) Patients that are undergoing a series of treatments: I acknowledge that complete compliance to my skin care program will enhance the outcome of my microdermabrasion treatments. This includes the use of SPF 30 sun protection over the treated areas on a daily basis during my treatment series. _(Required) I understand that there can be no guarantee as to how effective the outcome of my treatment(s) will be. There also can be no guarantee that dark discoloration (e.g. hyperpigmentation or melasma), stretch marks, or fine lines and wrinkles will be reduced or fade. It has been explained to me, and I understand, that these conditions will respond much better when part of an overall skincare program. _(Required) Consent(Required) I agree to the privacy policy.I have read and initialed each paragraph and have been satisfactorily informed of the benefits, risks, and complications in regards to microdermabrasion. I consent to this microdermabrasion treatment today and for all subsequent microdermabrasion treatments.Signature Δ