Treatment Informed Consent Form
Chase Beauty/Amanda Smith-Jens
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DMK Enzyme Therapy
DMK procedures are results-orientated and are designed to improve skin conditions. These are non-invasive treatments that use the body’s chemistry to induce lasting results. DMK enzyme therapy uses a process known as hydrolyzation, which turns dead protein cells into a weak acid that is then flushed from the skin. The enzyme formulations contain pure ingredients, and adverse reactions are very rare. You may experience: — Break-outs - enzyme therapy cannot cause any breakouts to occur, however congestion and trapped sebum plugs may be released, resulting in a superficial break out. — Dry, tight patches – this is where dead protein cells are still attached to the epidermis and have not been released. — Underlying pigment due to the aging process may move to the surface. This is due to the hydrolyzation of dead protein cells making the area look darker to the eye. — The client may experience redness, heat, and a slight stinging sensation for the first two days (This is most common in the more aggressive DMK treatments). — DMK Enzyme Therapy is activating the skin to function normally, so it may have a different texture while undergoing treatments. Each person’s experience will be different. The purpose of this form is to make sure you are well informed. If you have any questions after the treatment, please contact me with any concerns. I have read what I may experience due to treating my skin with enzyme therapy, and I understand that these treatments do not typically aggravate pre-existing or underlying conditions.
Chemical Peels and Enzymes
These special noninvasive skin performance treatments remove the outer layers of micro damaged skin—signaling new cells to emerge, increasing collagen, elastin and hydration levels, thereby producing clearer and more younger looking and acting skin. Additional benefits may include the drying of active acne, dislodging or purging of blackheads, reduction of superficial wrinkles or scarring, improving the appearance of mature or aging skin, correcting sun damage, lightening pigmentation disorders such as sun or age spots, and controlling the effects of other health and aging skin challenges. Compliance in your skin care program will determine the level of success and outcome of your treatment. Effective, long term results are dependent upon you. Consistency with your recommended continuance of proper home skin care products exclusively as prescribed by your licensed skin care professional cannot be emphasized enough. It is strongly advised you continue your professional in-clinic appointments as scheduled. Report any changes in health, diet, lifestyle or any reactions to your esthetician or physician. Apply sunscreen as directed by your esthetician or physician, avoid excess sun exposure and avoid tanning beds. Inform your esthetician or physician of any recreational plans for the week following your treatment. No guarantee is made or implied regarding results, peeling times or level of discomfort. Your treatment may involve the application of several peels at one, two or four week intervals, as determined by your esthetician. It may include the use of skin brightening agents and sun protection products. Depending on your treatment, you may experience some temporary discomfort, including stinging or warm flushing, similar to a mild burning sensation. This is NORMAL and generally fades within several minutes. During the few minutes following the initial treatment, you will experience tightening of the skin to varying degrees. The skin can appear red and become progressively rosier, occasionally turning a tan to brown color, depending upon formula and application variances. For superficial peels no visible peeling will occur, although very mild flakiness is sometimes possible. Break outs do sometimes occur following any peel, especially if exfoliants are not regularly used on the skin. Do not pick at skin, and keep following your proper homecare regimen. Most superficial breakouts will clear up on their own within a week or so. Please contact me with any concerns. For deeper depth peels, most individuals experience peeling starts at day five but can be as early as 48 hours. It is impossible to predetermine how much peeling will occur. Deeper penetration and more active solutions may result in sensitivity for several hours after the procedure, with some significant peeling for up to ten days. Your skin can feel tight, dry and you may experience redness for up to ten days. This type of peel will never be performed on the first treatment, it is a treatment the client must work up to. The skin will be prepped for two or more weeks utilizing proper homecare before this kind of peel is administered. To enhance your treatments and relieve discomfort for the period following your treatment, you are advised to do the following: • Drink a full glass of tepid water immediately after treatment and a total of eight glasses in the following eight hours. • Use only professional skin care products recommended by your esthetician or physician. • Notify your esthetician or physician of ANY concerns. • Do not use tanning beds, and avoid sun exposure as much as possible. Apply sunscreen DAILY. Steps to remember post-peel: • Avoid all sun exposure. • Avoid exercise and sweating for 48 to 72 hours. • Avoid having the shower spray directly on the face. • Do not pick, rub, or unnecessarily touch the face. • Minimize facial expression. • Sleep on back. • Shampoo with head tilted backward to avoid shampoo on skin.
Dermaplaning
What is Dermaplaning: Dermaplaning is a form of manual exfoliation similar in theory to microdermabrasion but without the use of suction or abrasive crystals. A sterile blade is stroked along the skin at an angle to gently scrape 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, and evens skin tone. 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 chemical peels. Due to the contours of the face, certain areas of the face (such as the eyelids and nose) are not treatable using this method. What should you expect during/after your treatment: 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. I take every precaution to ensure that your skin is well hydrated and calm following each session. However, you may experience excessive dryness or even some peeling between sessions, which may or may not be normal. Always contact me if you have any concerns. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours. Dermaplaning may cause minor superficial abrasions which may not appear until a day or two following your treatment. If this should occur, please contact me so that I can do a post-treatment follow up with you. Superficial break outs do sometimes occur following dermaplaning, especially in more acne-prone skins. Do not pick at skin, and keep following your proper homecare regimen. Most superficial breakouts will clear up on their own within a week or so. Please contact me with any concerns. After your treatment, SPF 30+ MUST be worn at all times. Tanning beds should never be used. Is satisfaction guaranteed: The majority of my clients receive noticeable, satisfactory to above average results with regular 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 management programs. 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 thick pigmentation • Moles in area to be treated • Oral blood thinner medications • Recent use of topical agents such as glycolic acids, alpha-hydroxy acids and Retin-A • Rosacea • Scleroderma • Skin Cancer • Sunburn • Healing Tattoos • Telangiectasia/erythema/redness may be worsened or brought out by exfoliation • Thick, dark facial hair or Diagnosed PCOS • Uncontrolled diabetes • Use of Accutane within the last year • Vascular lesions Post-Treatment/Home Care: 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 treatment cream and follow with SPF 30+ sunscreen.
Hydrafacial
HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from HydraFacial will vary from person to person. What to expect: • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity. • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. • Client experiences may vary. Some clients may experience a delayed onset of these symptoms. • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results. • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.
Keratin Lash Infusion
Although every precaution will be taken to ensure your safety and well-being before, during, and after your eyelash lift, please be aware of the following information and possible risks. Please initial: __ I understand that there are risks associated with having an eyelash lift. __ I understand that as part of the eyelash lift procedure, eye irritation, eye pain, eye itching, discomfort, and in rare cases, eye infection or blurriness could occur. __ I agree that if I experience any of these conditions with my eyelashes or eyes, that I will contact my technician; if I choose to consult a physician, it will be at my own expense. __ I understand that the instruments, tapes, cleaners, eye gel pads, adhesives, and/or removers may irritate my eyes or require a physician’s follow-up care, even though my technician utilized correct techniques and followed proper safety protocols. __ I understand that an eyelash lift will lift my natural eyelashes. Depending on my natural eyelash length and strength, results may vary. __ I understand and agree to the care instructions provided by my technician for the use and care of my eyelashes after the eyelash lift. I realize and accept that the consequences of failure to adhere to these instructions may cause the eyelashes to not stay as lifted as long as originally told. __ I understand and consent to having my eyes closed and covered for the entire duration of the procedure. I agree to the following eyelash lift care and maintenance instructions: No water can come in contact with the eye area for 24 hours after the applications. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read the above information. If I have any concerns, I will address these with my esthetician/technician. I give permission to my esthetician/technician to perform the eyelash lifting procedure we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician/technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician/technician 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 that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician/technician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.
Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:
Treatment I am consenting to:
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Hydrafacial
Keratin Lash Infusion
DMK Enzyme Therapy
Perfect Derma Peel
Get Glowing Micro Peel
Custom Facial
I hereby consent to and authorize the esthetician to perform the following treatment:
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I voluntarily agree to undergo this treatment after the nature and purpose of this treatment has been explained to me, along with any potential risks and hazards involved:
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I understand that no specific guarantees of the results can or have been made, and that there is the possibility that I may require additional treatments to obtain the expected results at an additional cost:
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I understand that it is imperative to my health and safety that I disclose all of the information requested in the New Client Intake Form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, prescriptions, or supplements being taken orally and/or topically, and any past reactions to products or medications:
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I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.
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Documentation only
Consent for Treatment
I understand that if I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform the above treatment we have discussed and will hold her/them and her/their staff harmless and nameless from any liability that may result from this treatment. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. 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 that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed.
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