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CONSENT FORM FOR VIBRADERMABRASION

I, consent to and authorize an Aesthetician and/or members of Dermatology Partners to perform a vibradermabrasion procedure and related services to me.

I understand that the vibradermabrasion involves the use of a vibrating, abrasive paddle to remove the top layers of the skin. This treatment should be used as part of a complete skin care program to maximize the overall benefits. A skin care program has been recommended to me as part of this treatment.

The nature and purpose of the treatment has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction.

I understand that the treatment may involve the risk of complications or injury from both known and unknown causes and I freely assume these risks. Possible side effects of the treatment area can include mild redness of the skin, irritation, local swelling, mild discomfort or tenderness, pimple-like bumps, dry skin, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores.

I certify that I have read this entire consent and that I understand and agree to the information provided in this form. I certify that I am a competent adult of at least 18 years of age, or that, if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian having legal custody will also be required before treatment. This consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

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

I have received and understand the post care recommendations as follows:

No sun exposure for 48 hours

Use of a gentle cleanser only

Acid washer may be resumed 48 hours after treatment

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