Informed Consent: Dermaplaning

Name*

First NameLast Name

Date of Appointment:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Date of birth*

Email*

example@example.com

Referred By (name):*

Please read the following information and acknowledge that you understand and accept all provisions by signing below.

I acknowledge and understand that while the goal of this treatment is superficial exfoliation and the removal of vellus hair (peach fuzz), I may receive added improvements such as reduction in the appearance of fine lines & temporary fading of pigmentation. I acknowledge that the Dermaplaning treatment is not an exact science and that no specific guarantees can or have been made concerning the expected result. I understand that the degree of improvement is variable and occasionally will see no visible improvement and another form of treatment may be required.

I understand that this procedure uses a Dermaplaning blade, which is mildly abrasive therefore I will follow the explicit instructions of my skincare therapist.

I have been advised of any alternative treatments which may address my primary concerns.

I understand, that during the course of treatments, my skincare specialist may discover other or different conditions that may require additional procedures than planned. I understand that my skincare specialist may refer me to an appropriate medical care provider if necessary.

I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur.

If I am prone to herpetic outbreaks, I understand that I may be advised to see a physician about appropriate prescriptions or supplements to control outbreaks prior to treatments. Take medicine 1 week prior to appointment.

I acknowledge that the success of my treatment depends on me and I have an obligation to follow the written and spoken instructions concerning pre and post treatment care in order to achieve optimal results.

I understand multiple treatments are recommended to see optimal results. The cost of treatment has been disclosed to me and I understand that payment is due at the time services are rendered.

I am over 18 years of age or have parental consent form signed and attached.

I will call to inform my skincare specialists of any complications or concerns as soon as they occur.

Please list all current medications including over the counter / herbal supplements:*

Please click next to each sentence to acknowledge:*

	I agree
No use of glycolic acid 24 hours pre/post
No use or retinol 24 hours pre/post
No use of benzoyl peroxide 24 hours pre/post
No use of salicylic acid 24 hours pre/post
No tanning 24 hours pre/post
No bleaching products 24 hours pre/post
No waxing, laser, IPL 24 hours pre/post
I agree to use recommended SPF
I do not have active cold sores
I have not used accutane in the past year

Precautions: Please click next to each sentence to accept and acknowledge*

	I agree
Nickel sensitivity may be a contraindication for Dermaplaning. I release provider from liability if my nickel allergy is not disclosed or unknown.
I understand that, although unlikely, there is a chance that Dermaplaning may cause a superficial scrape or nick on the skin.
I understand that I need to remain still and quiet during the Dermaplaning procedure. Failure to do so may result in a scrape or nick on the skin.
If I do need to speak, cough, sneeze or move during the procedure I understand that I should raise my hand, allowing the provider to cease the procedure.
I understand that children are not allowed in the treatment room during the Dermaplaning procedure.

I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to Dermaplaning treatments and all my questions have been answered to my satisfaction. I hereby release Dolce Medical Spa, Organic Salon & Salt Room and any of its employees against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the Dermaplaning treatment.

By typing my name below, I acknowledge this document.*

Date*

Date