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Dermaplaning Health Intake Form 2022

Dermaplaning Health Intake Form 2022

Hi there, please fill out and submit this form.
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    Hello and Welcome to Spa Liz & Co.!

    Are you a new client?
    Has it been 3 months since your last visit?
    Or a year since you updated your Health Intake Form?


    Please fill out this form a minimum of 72-hours before your appointment, or your appt may be canceled. We use this form to ensure you are not contradicted for your booked service(s). Each service category has its own form.

    We can't wait to see you at the spa!
    If you have any questions, please reach out by texting 414-253-3534.

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    We will use this number to send text appointment reminders and any additional appointment communication.
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    Pick a Date
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    For minors under 18 years of age, please click here for appointment information.
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    Spa Liz generally handles all communications via texting. However, if you prefer another way, we will try our best to accommodate that.
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    By entering your emergency contact, you are giving Spa Liz and Co. the right to contact this person in case of emergency and providing permission to Spa Liz to share the details of the situation. Spa Liz will always contact the appropriate emergency personnel first. Please include their Full Name, Phone Number & Relationship to you. 
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    Dermaplaning is a form of manual exfoliation similar in theory to microdermabrasion but without the use of suction or abrasive crystals. An esthetician grade, sterile blade is stroked along the skin at an angle to gently "shave off" dead skin cells from the epidermis. Dermaplaning also temporarily removes the fine vellus hair of the face, leaving a very smooth surface. As with any type of exfoliation, the removal of dead skin cells allows home care products to be more effective, reduces the appearance of fine lines, even skin tone, and assists in reducing milia, closed and open comedones, and minor breakouts associated with congested pores. Dermaplaning can be an effective exfoliation method for clients that have couperose (tiny blood vessels near the surface of the skin), sensitive skin, or allergies that prevent the use of microdermabrasion or chemical peels. Due to the contours of the face, certain areas of the face (such as eyelids and nose) are not treatable using this method.
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    As your esthetician, I will perform a thorough skin analysis prior to your first dermaplaning. If dermaplaning is not appropriate, you will be informed during this session and an alternative treatment may be recommended instead. If dermaplaning is not contraindicated, maximum results are obtained by participating in a series of treatments plus following a home care regimen. I will review your current daily regimen and skincare products, advise you on which products you should continue to use, and recommend any additional products to your regimen to enhance your desired outcome.
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    The majority of my clients receive noticeable, satisfactory to above average results with a series of treatments and a commitment to a daily skin care regimen. However, this outcome cannot be guaranteed as maximum results are highly dependent on age, cumulative sun exposure, health, lifestyle, genetic traits, general skin condition, and willingness to follow recommended protocols. Be aware that many changes may occur deeper within the skin over time. To continue the maintenance of your skin after you complete your treatment(s), I may inform you of long-term age managment programs.
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    Contraindications:

    Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for dermaplaning treatment and must be disclosed prior to treatment. 

    • Active acne
    • Active infection of any type, such as herpes simplex or flat warts
    • Any raised lesions
    • Any recent chemical peel procedure
    • Chemotherapy or radiation
    • Eczema or dermatitis
    • Family history of hypertrophic scarring or keloid formation
    • Hemophilia
    • Hormonal therapy that produces this pigmentation
    • Moles
    • Oral blood thinner medications
    • Pregnancy
    • Recent use of topical agents such as glycolic acids, alpha-hydroxy acids, and Retin-A
    • Rosacea
    • Scleroderma
    • Skin Cancer
    • Sunburn
    • Tattoos
    • Telangiectasia/erythema may be worsed or brought out by exfoliation
    • Thick, dark facial hair
    • Uncontrolled diabetes
    • Use of Accutane within the last year
    • Vascular lesions
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    Post Dermaplaning Instructions for 48 hours:

    • No direct sun
    • No exfoliation
    • Use a Zinc Oxide based sunscreen to prevent hyperpigmentation & sunburn
    • Avoid the use of Retin-A, Retinol, Renova, Alpha or Beta Hydroxyl Acid products
    • Avoid swimming and tanning beds
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    Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided. Direct sunlight exposure is to be completely avoided immediately following the treatment ( including any strong UV light exposure or tanning beds). Although SPF 30+ should already be a part of your daily skin care, after dermaplaning, SPF 30+ must be applied daily to the treated area for a minimum of two weeks. Twice daily cleanse the treated area with a post-treatment cleanser, followed by a serum or cream and follow with SPF 30+ sunscreen.
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    I acknowledge that no guarantee has been given regarding the condition of my skin or the percentage of improvement expected following treatment. I understand that no specific results are guaranteed. My signature below is an acknowledgment that I have read and understood the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform Dermaplaning treatment. I agree to hold harmless Spa Liz & Company, LLC, for any adverse reactions due to omitted information and/or misinformation on the Client Profile and/or from actions that deviate from pre- and post-care procedures.
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    This may be necessary for the treatment.
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    I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and have had sufficient opportunity for discussion to answer any questions. I understand the procedure and accept the risks. I do not hold the (Aesthetician, Massage Therapist, Electrologist, Employee, Owner) responsible for any of my conditions that were present but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today. I understand and agree to Spa Liz's Policy Agreement by signing below.
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    This may be necessary for the treatment.
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    Spa Liz & Co.'s Policies:

    • All appts are confirmed with a credit card on file.
    • Failure to submit a Health Intake Form 72 hrs before an appointment may result in cancellation of the appointment.
    • Forms can be found on the service and scheduling page.
    • As a courtesy, we do try to send forms via SMS. However, if you don’t receive one, please go www.spalizandco.com/scheduling to fill it out.
    • It is up to the client to fill out the form(s) correctly and completely. Policies are still enforced even if forms are not completed and returned.
    • 24-hour notice of cancellation is required before your appointment.
    • If an appointment is canceled within 24-hours, 50% of the total service fees will be charged to the credit card on file, or an invoice will be sent before another appointment can be made. 
    • Failure to give 24-hour notice or a No Show/No Call will result in 100% of the service fees being charged to the credit card on file or invoice sent before another appointment can be made.
    • If late for an appointment (varies depending on appointment length), it will still end on time, or the appointment will be canceled and full payment required.
    • All packages expire one year from the purchase date unless otherwise noted.
    • All sales are final on products, services, and packages. Therefore, they are non-transferable, non-refundable, and cannot be substituted.
    • No one besides who the appointment is for is allowed in the spa. You will be asked to reschedule and pay the service cancellation fee if the accompanying person can not wait outside.
    • Minors receiving service must have a legal custodian/parent. Please see FAQ for more information regarding minors.
    • If you have any questions or concerns, please go to the F.A.Q. page found under the Home section at www.SpaLizandCo.com.

    Consent to Treatment:

    • I have had any questions or concerns answered before treatment today.
    • I will address any future questions with my skin therapist before treatment.
    • I give permission to my therapist to perform the facial treatment we have discussed and will hold her and her company harmless from any liability that may result from this treatment.
    • I have given an accurate account of the questions asked above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically.
    • I understand my aesthetician will take every precaution to minimize or eliminate adverse reactions as much as possible.
    • I am willing to follow recommendations made by my aesthetician for a home care regimen that can minimize or eliminate possible adverse reactions.
    • If I have additional questions or concerns regarding my treatment or suggested home products / post-treatment care, I will consult the aesthetician immediately.
    • I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.
    • I certify that I have read and fully understand the above paragraphs and have had sufficient opportunity for discussion to answer any questions. I understand the procedure and accept the risks.
    • I do not hold the aesthetician responsible for any of my conditions that were present but have not disclosed the time of this skincare procedure, which may be affected by the treatment performed today.
    • I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure have been explained to me, along with the risks and hazards involved.
    • Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
    • I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
    • I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.
    • I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me.
    • In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
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    I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and have had sufficient opportunity for discussion to answer any questions. I understand the procedure and accept the risks. I do not hold the (Aesthetician, Massage Therapist, Electrologist, Employee, Owner) responsible for any of my conditions that were present but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today. I understand and agree to Spa Liz's Policy Agreement by signing below.
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