DPN Intake Form

DPN Treatment - Intake Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Medical History
Please give details about any condition
List all prescribed medications, herbs and supplements you are taking (include contraception)
Do you have any allergies? If yes, give details

Client Commitment Contract
I will not use any other products that have not been approved by my skincare professional while I am on their regimen.

I will not change the regimen given to me by my skincare professional without notifying or consulting them first.

I will replenish my products well before l run out, so that the best results may be achieved as recommended by my skincare professional.

I will not have other skin care treatments while l am being treated by my skincare professional.

I will inform my skincare professional of any medications/drugs that I start taking while using their recommended products.

I will use my sunscreen every morning, regardless of whether or not I will be going outside.

I will not get sunburned or wind burned while being treated by my skincare professional. You will not be able to use your active products; and we will not be able to do treatments on you (if you are seen in our studio).

I will inform my skincare professional if l elect to do any laser treatments or waxing for hair removal.

(For women) - I will inform my skincare professional if I get pregnant.

I agree to contact my skincare professional so we can adjust the home care regimen per their recommendations.

I agree to contact my skincare professional if my skin gets uncomfortably dry and irritated.
MOST IMPORTANTLY:

If we are unable to improve the condition of your skin due to factors beyond our control, but within yours, we reserve the right to decline treatments. (That is, if you are not following our instructions pertaining to home care, lifestyle issues, etc.
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Name

First NameLast Name

HOME CARE INSTRUCTIONS
Immediately after your removal procedure the area may feel irritated; redness and scabbing are a normal part of the healing process. Gentle cleansing is acceptable when a large area has been treated, however please follow these instructions closely to minimize any adverse reactions, and to aide with healing time.

1. Do not directly touch the treated area for 24-48 hours following treatment to minimize the risk of infection, keep the area dry and refrain from environments that cause overheating, perspiring or sweating.

2. Do not pick at the treated area, premature removal of scabs may result in hyperpigmentation, infection, or scarring.

3. Use mild cleansing products around the treated area during bath time, remembering to keep the treated are protected and dry (band-aids may assist with protection during the cleansing process,however be sure that the band aids are not affixed to any parts of the treated areas).

4. Use a gentle massaging motion when cleansing and patting motion when drying the skin.

5. Refrain from applying makeup for at least 24hours, although its preferable to wait until the skin is completely healed.

6. Refrain from using products or receiving treatments such as skin lightening, exfoliation and peeling techniques for a minimum of 14 days post healing.

7. The average healing time is 6 days. In some cases you may notice that your skincare practitioner has immediately removed larger skin irregularities. In this case, please continue to be gentle and follow the directions above as the skin is still undergoing a healing phase. Other treated areas may darken and scab and fall off, in some cases it can take as long as 10-14 days. Gentle daily cleansing after the "no touch" period will assist the skin with healing faster.
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DPN Treatment - Intake Form

DPN Form

Client Commitment Contract

HOME CARE INSTRUCTIONS