Dermaplane Consent and Health Questionnaire Form

Dermaplane Consent & Health Questionnaire

Please fill out completely
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact *

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
How did you hear about us?*

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It is very important that you read ALL of the information in this document, sign it, and submit. This confirms that you understand precautions prior to this treatment.

I confirm I have disclosed to my skin care professional any surgical procedures, laser treatments or facial procedures that I have had or intend on having in the future as well as the following:

- I have not received Botox or fillers within 1 week of this appointment.

- I have not used any form of Vitamin A (Retin-A, Renova) within the past 5 days and will not use Vitamin A for 5 days after the service.

- I have not had any recent chemotherapy or radiation treatments in the past year.

- I have not recently waxed or used a depilatory (such as Nair) on the area being treated today.

- I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters or cold sores.

- I do not have broken skin on the areas to be treated, visible inflamatory lesions, sunburn or windburn skin.

- I have not had any other peel treatment of any kind within 14 days of treatment. I understand I cannot have another treatment within 14 days of this treatment, whether the treatment is performed at this location or any other location.

- I agree to refrain from excessive sun exposure or the use of a tanning bed while I am undergoing treatment and during the 14 days following the end of the treatment, and the use of Broad Spectrum SPF is mandatory.

I understand that the following conditions PRECLUDE me from having this treatment currently and verify NONE of these conditions apply to me at this time:

---Broken skin on areas to be treated

---Sunburn or windburn skin

---Visible inflammatory or inflammatory lesions

---Herpes virus (cold sores) on mouth

---Laser Hair Removal within 6 weeks

---Use of glycolic acid products

---Use of Retin-A, Renova, retinoids (Vitamin A) in the last 4 weeks
I agree to, and adhere to, the above conditions.*

Yes
I consent for my skincare professional to perform Dermaplaning treatment.*

YESNO
I understand that Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair from the face, and provide light exfoliation*

YES
The nature and purpose of Dermaplaning has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction prior to procedure*

Yes
I agree to complete this entire form and be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption and/or recreational use of controlled substances, may affect the outcome of the treatment*

Yes
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.*

Yes
I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin. Some of the benefits include lessening of pigmentation, reduction in appearance of fine lines and wrinkles, and control of certain conditions such as acne or occasional breakout.*

Yes
If an enzyme or chemical peel is included with this treatment, I understand that the sensation and penetration of the treatment 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 the virus is already present in the body. I understand that although complications are very rare, sometimes they may occur, and that prompt treatment is necessary. In the event of any complication, I will immediately contact the facility where treatment was performed. I understand that every precaution will be taken to minimize or eliminate negative reactions such as blisters, redness, or irritation if possible.*

Yes
How would you describe your skin?*

NormalCombination (ex. Oily Tzone but dryness on chin)DrySensitiveOilySun DamagedUnsure
What are your specific skincare concerns or like to improve?*

Dryness/ flaky skinFine Lines and wrinklesBlackheadsAcneLoss of FirmnessAcne ScarsClogged PoresSkin TextureEnlarged PoresHyperpigmentation/Uneven toneRednessSkin SensitivityRosaceaOily SkinSkin dullness/brighteningOther
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)NoneOther
What is the skincare brand you use?*

I don't use skincareOther
Medical History Questionnaire
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsTopical AntibioticsAccutaneDifferinRetin-ATazoracRenovaHydroquinoneNo/NoneOther
When, and how long have you been taking these products?
Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO
Have you received botox or fillers?*

YesNo
You selected "Yes" to Botox or fillers, please list what location on your face and when?
Any known allergies?*

AsprinLatexFruitsShellfishLidocaineFragrance/Essential oilsTree NutsDairySunscreenPollenGlutenEggSoybeanNoneOther
Please list medications and/or supplements you are currently taking:*
Medications / Supplements
Have you ever experienced claustrophobia?*

YESNO
Have you ever experiences vertigo or issues laying flat?*

YESNO
Have you experienced any of these health conditions in the past or present?*

Cancer/ Systemic diseaseHigh Blood PressureDiabetesHeart disease/ConditionsArthritis/BursitisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold sores/blistersHIV/AIDSLupusCataractsDepression/AnxietyContact LensesHeadaches/ MigranesMetal ImplantsBruise easilyPacemakerSmoker/Former SmokerHepatitisEczemaHay FeverThrombosisPhlebitisMenopausalVaricose VeinsHypothyroidismHyperthyroidismNoneDental metal fillings/bridgeworkOther
You selected "YES" to Varicose veins. If Varicose veins are present on the face specifically, and tends to be severe, please indicate it here for the treatment plan to be adjusted:

YesNo
You selected "YES" for Phlebitis, please be advised due to pain, swelling and risk for blood clots any massage will be omitted to reduce risk. Please confirm that you are cleared by a physician to have this treatment:

Yes
You checked "YES" to Cataracts, please be advised due to pressure applied from massage or exfoliation during a facial, this treatment shouldn't be performed with any recent Cataract surgery. Please confirm that you are post surgery and/or cleared by a physician to have this treatment:

Yes
For WOMEN: Please select All that apply:

Taking birth controlPregnant or breast feedingTaking hormone replacementExperience hormone imbalancesNone of the aboveOther
For MEN: Please select All that apply:

Shave with an Electric ShaverShave with RazorExperience skin breakouts after shavingExperience Ingrown hairNone of the aboveOther
Informed Consent / Waiver Release Policies
Informed Consent / Waiver Release

I hereby agree to this treatment. I am aware that products used in facials, skincare treatments, and homecare may contain tree nuts, sulfur, dairy, fruit, and gluten. I acknowledge that the skin care professional with Array Esthetics & PMU may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of adverse reaction to a product used in facials. I will inform my skin care professional before treatment of severe allergies, as this may make me unable to receive the service.

I am aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications, and answered all questions honestly on the above form, and agree to update Array Esthetics & PMU as to any changes. I understand it is my responsibility to disclose all medical, medicinal, and skin history, as Array Esthetics & PMU will not be responsible for reactions caused by undisclosed medical history.

I understand that the services offered are not a substitute for medical care. I understand that my skin care professional with Array Esthetics & PMU will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and post care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home care routine, I will inform my skin care professional immediately.

I release and hold harmless the skin care professional with Array Esthetics & PMU from any liability for adverse reactions that may result from this treatment.

Policies

1. If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is the policy of Array Esthetics & PMU to provide you with the best professional service and products customized for your skin goals.

2. 24- hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. By clicking the box, I’m acknowledging I have read, understand, and agree with the terms of these policies.

This agreement will remain in effect for the procedure and all future procedures conducted by my technician for one year from the date of this signed form. I understand that this agreement is binding and that I have read and fully understand all information listed above.
I consent to any relevant photographs/videos being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of the company.*

Yes
[Optional/Requested] I consent to Array Esthetics & PMU using “before & after” photos/videos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs/videos by contacting the company, which will then discontinue use of said media.*

YesNo
Date*

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Client Signature*

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Parent/Guardian Signature if client under 18 years old

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Dermaplane Consent & Health Questionnaire

Medical History Questionnaire

Informed Consent / Waiver Release Policies