Facial Consent Form

Client Consent Form & Liability Waiver
I hereby consent to and authorize Pure Esthetics/Cindy Brazinski to perform the following procedure:
Enter requested procedure here.
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me.

I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications

I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is a possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment of suggested home product/post-treatment care, I will consult the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. 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 skin care procedure, which may be affected by the treatment performed today.
Full Name
Signature

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Date

MonthDayYear
Date

Photo/Video Release

As a small business, I utilize social media to promote my services. I don't want to do anything that makes you uncomfortable so I ask that you complete the following questions to let me know if i have your permission to use photos or videos, and whether or not you'd like to be identified. Thank you in advance.
I hereby authorize Pure Esthetics/Cindy Brazinski to use my photos and videos. I understand this may include social media, advertisement, promotional material, and/or other similar ways. My consent is freely given without expecting payment.*

AgreeDisagree
I release Pure Esthetics/Cindy Brazinski from any and all liability that may arise from the use of my photos/videos.*

AgreeDisagree
I prefer that:*

My name be usedMy name NOT be usedMy social media is tagged in my photo/videosMy social media is NOT tagged in my photo/videos
I understand that I can revoke this release at any time and that the use of my photos/videos authorized by this release will immediately cease.*

Understood

Dermaplaning Specific Consent Form

Only necessary to complete if you are receiving any dermaplaning.
Please check each box after reading and sign below.

I understand that dermaplaning is the process of removing superficial layers of dead skin cells on the skin’s surface by the use of a sterile blade while removing most of the vellus hairs.I have been explained the process of dermaplaning by my esthetician and have had the opportunity to ask any questions.I understand that results may not be seen in a single treatment. The ideal plan of treatment is to have at least one dermaplaning treatment as directed by my esthetician to enhance treatment as directed by my esthetician to enhance any skin conditions and follow up with maintenance treatments as needed.I understand for optimum results, the importance of following the post-home care system recommended to me by my esthetician.I understand that there may be an unforeseen risk with dermaplaning such as cutting, scraping, or abrading the skin with the blade.I am satisfied with the information provided to me regarding dermaplaning and agree to have the procedure performed on me.I understand that I must wear an SPF of 30 or greater at all times throughout the course of treatment.I understand that I must discontinue the use of retinol or Retin- A, 7 days prior to a dermaplaning procedure.I understand to wait 7 days after Botox and 10 days after fillers to receive a dermaplaning treatment.
*Is there anything that we should be aware of before your dermaplaning procedure?
By signing below, I certify that I have read and fully understood the contents of this consent form and that the information I provided above is complete, accurate, and up-to-date to my knowledge. I hereby consent to theDermaplaning procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures. I release the esthetician, management, and staff from any and all liability associated with any injuries or current or future conditions resulting from the skincare procedures and products.
Client Full Name Name(Print)
Signature

Clear
Parent or Guardian Signature (if client is under 18 yrs)

Clear
Date

MonthDayYear
Date

Dermaplaning Information Sheet
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
- 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 worsened or brought out by exfoliation
- Thick, dark facial hair
- 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+ mustbe applied daily to the treated area for a minimum of two weeks. Twice daily cleanse the treated area with a posttreatment cleanser, followed by a serum or treatment cream and follow with SPF 30+ sunscreen.
Client Name(Print)
Clients Name (Signature)

Clear
Parent or Guardian Signature (if client is under 18 yrs)

Clear
Date

MonthDayYear
Should be Empty:

Facial Consent Form

Medical History

Skin Care History

Client Consent Form & Liability Waiver

Photo/Video Release

Dermaplaning Specific Consent Form

Dermaplaning Information Sheet