Dermaplane Intake and Informed Consent

  • Client Questionnaire

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Okay To E-Mail?
  • Okay to Call?
  • Okay to Text?
  • Format: (000) 000-0000.
  • Do we have permission to show your non-identifying photos for social media purposes?
  • How did you hear about Estie Co.?

  • Medical History & Intake

  • What concerns you most about the overall appearance of your skin? (check all that apply)
  • How would you describe your skin?
  • How would you describe your stress level?
  • Do you feel your stress level may be affecting the health of your skin?
  • Are you in good health overall?
  • Are you currently under the care of a physician?
  • Do you have any allergies to foods, skin care ingredients, or medications?
  • Are you currently on any medications either topical or oral?
  • How do you heal after an acne breakout, cut, or scratch?
  • Do you smoke?
  • Are you prone to cold sores?
  • Do you have an allergy to Latex?
  • Do you tan in the sun or in tanning beds/booths?
  • Do you wax your facial skin on a regular basis?
  • Have you ever had facials, chemical peels, microdermabrasion, or any resurfacing treatments?
  • Have you received Botox, Juvederm, or other dermal fillers within the last two weeks?
  • Rows
  • Rows
  • Please check the skincare products you are currently using:

  • Contraindications for Dermaplaning


    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 - within two weeks
    • 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, retinols
    • 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

  • I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company (Estie Co. LLC)  and/or skin care professional from liability.

  • Date
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  • Informed Consent

  • give my consent for Dermaplaning to be performed by Julia Detweiler.

    Dermaplaning is a physical exfoliation that removes dead skin cells and vellus hair from the surface of the face. This form of exfoliation smooths the skin and allows for the active ingredients in skincare products and treatments to penetrate deeper which increases their efficacy & anti-aging benefits. 


    Alternatives to dermaplaning include microdermabrasion and scrubs for exfoliation, and waxing, threading or cream depilatory for hair removal. There is no single treatment to replace dermaplaning. 


    I understand there are contraindications to this treatment, including but not limited to diabetes, cancer, active acne, bleeding disorders and the inability for blood to coagulate following injury. Certain medications including blood thinners, higher doses of Aspirin, and Accutane are contraindicated for this treatment due to increased sensitivity and/or the possibility of delayed clotting from a nick or cut. 


    I certify that I am not taking any of the above medications or experiencing any of the above conditions. Alternative treatments such as waxing to remove vellus hair and microdermabrasion for exfoliation, along with their associated risks, have been explained to me as other options.


    I understand this treatment involves the use of a specialized dermaplaning blade to remove dead skin cells and vellus hair. As with the use of any sharp instrument there is the possibility of injury. While every precaution is taken, I understand the risks and consent to receive treatment today.

  • Date
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  • Client Policies

  • Estie Co. will now require 24 hours notice for rescheduled and canceled appointments.
    There will be a 50% charge of service booked for last-minute (within 24 hours) cancellations or reschedules.

    90% of the service booked will be charged for no-call/no-shows. This will need to be paid before you are allowed to book another appointment. Refusal to pay will result in a ban from my schedule.

    If you are running 15+ minutes late for your appointment, there will be a 50% charge of the service booked and the appointment will need to be rescheduled.

    Sickness: Please, please do not come to your appointment if you are feeling sick AT ALL. Reschedule your appointment for a later date. This keeps everyone safe and allows Jules to continue working. There will be no exceptions for this, if you are sick, you will be sent home and charged 90% of the service.

     

    You can easily reschedule your appointment by going to the link that is sent to your email when you book. We know that last-minute things pop up so please make sure you reach out when canceling/rescheduling.

  • By signing below, I am agreeing to the policies stated above and agree to pay any penalties that may be charged by Estie Co. LLC in accordance to these policies.

  • COVID-19 Information & Liability Waiver

  • 1. Have you had a fever in the last 24 hours of 100°F or above?
  • 2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
  • 3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus type symptoms?

  • COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected. 


    Consent for Treatment 

    I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

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