Dermaplaning Facial And Peel Consent Form

Are you pregnant or lactating ?

YesNo

Are you wearing contact lenses ?

YesNo

Do you have semi-permanent make up ?

YesNo

Do you use a sunbed regularly ?

YesNo

If yes, when was your last sunbed session ?

Date

What skin care products do you use?

Are you on Roaccutane ?

YesNo

Are you on any other medication ?

Are you sensitive to any of the following:

Have you had any recent facials ?

YesNo

If yes what did you have ?

Have you had any non-surgical or surgical cosmetic treatments recently?

YesNo

If yes please specify:

Do you suffer with cold sores or active acne ?

YesNo

Do you have any other skin conditions ?

YesNo

If yes what skin conditions:

Have you ever had a reaction to any skin care products ?

YesNo

Possible Side Effects:

Bruising
Itching
Redness
Flaking or Peeling
Temporary uneven skin texture
Hair regrowth

I understand that there are risks involved in facials that use acids, micro needling and LED lights and I can discuss any concerns I have with the practitioner.

I have asked all the questions I have about the WOW facial and understand potential risks and complications.

I agree to follow all post care advice given to me by the practitioner.

I have answered all questions to the best of my knowledge and I am happy for the practitioner to commence with the wow facial.

Signature*

Date of Signature*

Date of signature

Dermaplaning Facial and Peel Consent Form

Treatment Questionnaire