Dermaplaning Informed Consent

1
Date* This field is required.
Date
Month
Day
Year
2
Name* This field is required.
First Name
Last Name
3
I understand that Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair from the face, and provide light exfoliation* This field is required.
Please Select
Please Select
Yes
No
4
The nature and purpose of Dermaplaning has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction prior to procedure.* This field is required.
Please Select
Please Select
Yes
No
5
I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness, mild irritation, and dryness. Additionally, nicks to the skin can occur due to the sharp surgical blade. The hair that grows back will not be darker or thicker, however I do understand that any hormone imbalance present within my anatomical system can alter the normal hair growth pattern.* This field is required.
Please Select
Please Select
Yes
No
6
If a chemical peel is included with this treatment, I understand that the sensation and penetration of the peel will be enhanced. This may cause skin irritation, mild discomfort, tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores, when virus is already present in the body. I certify that I have read this entire consent form and I understand and agree to the information provided in this form. I certify that I am at least 18 years of age. I will call to inform my esthetician of any complications or concerns as soon as they occur. I certify that I have read the above consent and I fully understand it and give my consent to the Dermaplaning treatment.* This field is required.
Please Select
Please Select
Yes
No
7
I understand that if I am pregnant or breastfeeding, I cannot receive a chemical peel during my treatment and I will notify my esthetician.* This field is required.
I understand
8
I understand that if I am using retinol products, I will notify my esthetician and I should not receive a chemical peel unless I've discontinued use for at least 14 days.* This field is required.
I understand
9
Please tell us why you've booked a facial treatment, your skin goals and biggest skin concerns you'd like addressed. Please also list your current skincare routine and products you're using.* This field is required.
10
Signature* This field is required.
Clear
11
Date* This field is required.
Date
Month
Day
Year
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