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Iris Beauty Solution appreciates your patronage and interest in Microdermabrasion. Microdermabrasion uses light abrasion to remove the stratum corneum --the outermost layer of skin, which consists of dead cells. This technique works to remove skin that has been damaged by the sun, as well as to reduce or eliminate scars. Microdermabrasion can also lessen and remove dark spots on the surface of the skin. The process requires no anesthetic and is not painful. Microdermbrasion of a scar is most effective when the scar is raised.  This treatment results in a clearer complexion with softer & smoother skin, reduces the appearance of aging, promotes collagen production, oxygenates and tightens the skin, while destroying harmful bacteria on the skin’s surface.

Please read and fill out this Disclosure and Release form completely, making certain that the address and telephone numbers are correct.  

Name:

Address/Province/City/Postal Code:  

Email:          Age: _______    Phone #:

Date/Time:

You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved.  This disclosure is not meant to frighten you. It is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.  

Microdermabrasion Consent  Form

I understand that there may be some degree of minor discomfort (i.e. stinging, pin-pricking sensation, hotness, tightness, burning or itching and that frosting, scabbing, swelling, and crusting are all common during healing. 

I understand that this is an aesthetic procedure and that to achieve maximum results, I may need several ongoing treatments over a period of time and that results are expected at no less than four treatments.

I understand that at any time, I may be referred out to a Dermatologist for a deeper peeling treatment and skin diagnosis.I understand that although complications are very rare, sometimes they may occur and that prompt attention/treatment is necessary. In the event of any complications, I will immediately contact the esthetician who performed this procedure.

I understand that I cannot get another treatment within 10-14 days of this procedure unless specified by my esthetician, whether the treatment is performed at this location or any other facility.

I understand that I cannot undergo any hair removal/laser procedures/Epilation services, and I must avoid any exfoliants or acid-based products for at least 48 hours following this procedure

I clearly understand and have been informed that any sun exposure following this treatment can result in hypo/hyperpigmentation of my skin and the use of sunscreen is mandatory. I understand that there is a 24 Hour Cancellation Policy. 

I realize that with any beauty service there may be certain risks which must be understood. I will be fully responsible for any and all results which may arise from these beauty services. I do hereby agree to Irina Kouzmina and Iris Beauty Solution, their employees and agents, free from any and all claims or suits for damage, for injuries or complications resulting from any beauty service provided by Iris Beauty Solution. The nature and purpose of the beauty services, the risks involved and the possibility of complications have been fully explained to me. I understand that no guarantee or assurance has been given by anyone as to the results that may be obtained.

By signing below I acknowledge that I have read and understand the above and all of my questions have been answered and that I consent to have the above beauty services.


Client Signature________________________________       Date:_______________