Lavender Falls Face & Body Spa LLC

Client Informed Consent Form






19239 Stone Oak Pkwy #201

San Antonio, Texas 78258

Phone: 210-446-0903


Online Booking Available

Treatment Consists of:

Microdermabrasion is the process of abrading away epidermal tissue using a diamond-tip wand and suction tool. This treatment removes dead skin cells from the skins surface and initiates cellular turnover at the dermis and epidermis levels in a safe controlled manner. Maintaining even cellular growth on the surface aids in the youthfulness of the skin’s appearance.

Microdermabrasion has been used to treat aging and sun-damaged skin, some types of acne and acne scarring, altered pigmentation, fine lines and wrinkles, and stretch marks. Results may include improved skin tone, fewer breakouts, and diminished appearance of scars, even skin color, refined skin pores, renewed elasticity, and a healthy glow.

Clients Acknowledgements:

Microdermabrasion is not recommended to keratosis sufferers, people with undiagnosed lesions, active rosacea or acne, weeping acne (stages 3 to 4) fragile capillaries, eczema, dermatitis, psoriasis or lupus. Active infection of any type such as Herpes simplex virus or flat warts. Telangiectasia/erythema may be worsened or brought out by skin exfoliation.

Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

      Accutane with the last year


I am not allergic to any of the ingredients in the prescribed treatment.

      Sunburn or Sun Exposure- 1 week prior to treatment.

      Recent Laser Treatments or Chemical Peels

      Electrolysis, Waxing , Depilatory Creams , Laser Hair Removal – 1 week prior to treatment

      No prescriptive topicals, abrasive scrubs or strong exfoliants – 1 week prior to and post treatment.

(Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol, glycolic acid, salicylic acid)

      Any products containing AHA or BHA, or benzyl peroxide or any exfoliating products that may be drying or irritating – 3 days prior to treatment.

      Pregnant or Breastfeeding


Cosmetic Injections:

      Botox/Dysport/Xeomin within the last week.

      Dermal Fillers within the last two weeks.

*Notify your aesthetician of any medical conditions & medications (Current & within the last 90 days).

Post Treatment Acknowledgement

      The skin will be red with mild swelling and might feel tight and sensitive to the touch. Although these symptoms may take 1-2 days to resolve completely, they will diminish significantly within the first 24 hours after treatment.

      No prolonged sun exposure 1 week post treatment.

      Sun protection of at least broad spectrum SPF 30 is recommended.

      Keep the new skin clean and moisturized

      Use of a gentle cleanser only.

      Cold compresses may be used as necessary.

      Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided.

      It is important to avoid irritating the treated skin with harsh chemicals, rubbing or tanning for one week.

      DO NOT scratch, pick, pull or abrade the treated skin, this could cause hyperpigmentation or scarring.

      Restart regular skin care regimen in 48 hours & Vitamin A (retinoid) products 3 - 7 days after last microdermabrasion treatment or as instructed by your aesthetician.

Side Effects:

Possible side effects include but are not limited to:

• Common side effects such as slight redness usually subside within a few hours after treatment.

• Uncommon side effects such as bruising, skin irritation and exacerbation of skin breakout can occur.

• Rarely, allergic reaction, pigment changes of freckles, moles or skin such as hypopigmentation (lightening) or hyperpigmentation (darkening) can occur and may resolve, but can be permanent. Scarring and textural changes are also rare side effects but can result from this procedure. There may be risks not yet known at this time.


      I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

      The microdermabrasion treatment has been fully explained and any questions or concerns that I have, have been addressed.

      I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

      I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

      Photographs May be taken for comparison for future treatments for my chart.


I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.


I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.


All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.







Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face & Body spa LLC for your aesthetic needs

Feel free to contact us at 210-446-0903 if you have any questions



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Signature Certificate
Document name: Microderm
lock iconUnique Document ID: 73dc5c994b4c64ea6a0f594f2f751742747697c4
Timestamp Audit
April 8, 2017 7:50 pm CSTMicroderm Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP