Dermaplaning Consultation Form

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

i understand that Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair on the face , and provides light exfoliation.* This field is required.

I consent

4

Have you ever had a dermaplaning facial preformed by a professional?* This field is required.

Yes

No

5

IF yes, when was the last time you had a dermaplaning facial?* This field is required.

Date

6

In the last 48 hours, have you had a peel, microdermabrasion, or tanned?* This field is required.

Yes

No

IF YES, We will need to schedule your appointment for another day!

7

What is your skin type?* This field is required.

Oily

Dry

Combination

Sensitive

8

Are you sunburned on your face right now?* This field is required.

Yes

No

IF YES, we will need to schedule you appointment for another day when your skin is healed

9

Do you have any allergies?* This field is required.

Yes

No

10

If yes ,Please list all your allergies/allergens.

11

I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage, climate, etc.* This field is required.

I consent

12

I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment and the use of a daily sun block protection is mandatory* This field is required.

I consent

13

I am not using Retin A, and have been off Retin A for at least 3 days prior to treatment. I will call my practitioner if I have any questions or concerns about my treatment* This field is required.

I consent

14

I have been advised not to exercise, touch, exfoliate or use any harsh products after my treatment.* This field is required.

I consent

15

I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness, mild irritation, and dryness. Additionally, nicks to the skin can occur due to the sharp surgical blade. The hair that grows back will not be darker or thicker, however I do understand that any hormone imbalance present within my anatomical system can alter the normal hair growth pattern.* This field is required.

I consent

16

If a chemical peel is included with this treatment, I understand that the sensation and penetration of the peel will be enhanced. This may cause skin irritation, mild discomfort, tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores, when virus is already present in the body. I certify that I have read this entire consent form and I understand and agree to the information provided in this form. I certify that I am at least 18 years of age, or I have a parental consent co-signed below. I will call to inform my aesthetician of any complications or concerns as soon as they occur. I certify that I have read the above consent and I fully understand it and give my consent to the Dermaplaning treatment.* This field is required.

I consent

17

Date

18

Signature* This field is required.