Med

Name

Birth Date

Date

Address

City

State

Zip

Cell Phone

E Mail Address

example@example.com

What concerns you the most about the overall appearance of your skin? (Check all that apply)

How would you describe your skin?Check all that apply

Please describe your concerns for your skin, and goals you have for your skin.

Please list all skin care products you are currently using at home.

Please list any professional skin treatments you’ve had in the past year.

Are you currently under the care of a physician?

Explain

Do you have any allergies to foods, ingredients or medications?

Are you currently on any medications either topical or oral?

Are you prone to cold sores? Yes No If yes, date of last cold sore?

If yes, date of last cold sore?

Date

Anything else we should know

The answers I have provided are true and correct to the best of my knowledge.

Client Signature

Date

Esthetician Signature

Date

I give my consent for the following procedure:

dermaplaning to be performed by, Tia Papatheodore - Licensed Esthetician.

Dermaplaning is a physical/mechanical form of exfoliation using a specialized dermaplaning blade for the removal of built up dead skin cells and vellous hair. Following treatment skin will be smoother, softer and better able to absorb the active ingredients in treatment and home care products.

I understand this treatment involves the use of the sterile, surgical blade to remove dead skin cells and vellous hair. As with the use of any sharp instrument, there is the possibility of nicks

I understand there are contraindications to this treatment, including but not limited to, diabetes (not controlled by diet or medication), cancer, active acne, bleeding disorders, the inability for blood to coagulate or the development of keloids following injury. Certain medications including blood thinners, higher dosages of Aspirin, and Accutane are contraindicated for this treatment due to 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

While every precaution will be taken to avoid nicks, cuts and scratches, I understand the risks and consent to treatment today.

Name

Client Signature

Date

Licensed Esthetician

Signature

Date

Medical Director

Signature

Date

What concerns you most about the overall appearance of your skin? (check all that apply)