Dermaplaning Consent Form

NOTE: This form is required to be filled out prior to a client's first dermaplaning procedure and updated before each following procedure at Simply You Skincare & Wellness.

Date*

Date

Name*

First NameLast Name

What is Dermaplaning?

A sterile scalpel blade is used to exfoliate soft vellus hair (peach fuzz) and dead skin cells. Dermaplaning leaves your skin brighter, smoother, glowing, and more youthful allowing better product penetration and flawless makeup coverage. Great for almost all skin types, especially those with sun damage, fine lines, dry skin, and dull skin.

Contraindications

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

Active acne
Thin/delicate skin
Active infection of any type, such as Herpes simplex virus, blisters, or flat warts
Sunburn or windburn
Use of some topical agents, including Retin-A
Any recent chemical peel procedure
Auto immune disorder
Eczema/Dermatitis
Skin cancer
Vascular lesions
Use of Acutane within the last year
Family history of hypertrophic scarring or keloid formation
Use of the following in the 24 hours before the procedure: glycolic acid, retinol, salicylic acid, bleaching agents, benzoyl peroxide
Waxing, laser or IPL in the 24 hours before the procedure

Post-Care (24+ hours)

Do not use the following: glycolic acid, retinol, salicylic acid, bleaching agents, benzoyl peroxide
No waxing, laser or IPL
Avoid the sun and wear SPF

Precautions

Please agree to the statements below

Nickel sensitivity may be a contraindication for dermaplaning. I release provider from liability if my nickel allergy is not disclosed or unknown*

I agree

I understand that, although unlikely, there is a chance that dermaplaning may cause a superficial scrape or nick on the skin*

I agree

I understand that I need to remain still and quiet during the dermaplaning procedure. Failure to do so may result in a scrape or nick on the skin.*

I agree

If I do need to speak, cough, sneeze or move during the procedure I understand that I should raise my hand allowing the provider to cease procedure*

I agree

I understand that children are not allowed in the treatment room during the dermaplaning procedure.*

I agree

I understand that, in rare circumstances, an adverse reaction to dermaplaning may occur, which includes non-itchy, non-inflamed bumps on the skin that may last 2+ days.*

I agree

I understand that my homecare products may effect how my skin reacts to the dermaplaning procedure.*

I agree

I certify that I have read, and fully understand, the above information and that I have had sufficient opportunity for discussion to have any questions answered. I understand that if I have any concerns, I will address these with my esthetician. I give permission to Allie Bebenroth (esthetician) to perform the dermaplaning procedure we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions on the New Client intake form, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand she will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a gentle product regimen, wearing sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by my therapist. I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.*

I agree

Signature*