Glow - Waxing & Dermaplane

I give my consent for Dermaplaning to be performed by Nicole Lamb.

Dermaplaning is a physical exfoliation that removes dead skin cells and vellus hair from 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 dosages 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.

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.

Name:*

Signature*

Date*

Date

Have you taken Accutane within the past 6 months?*

YesNo

If so, provide date of last dose:

Are you pregnant, diabetic, or receiving cancer treatment?*

YesNo

Have you recently received any exfoliating treatments or chemical peels?*

YesNo

Are you using acne medications (prescribed or over the counter) including: Retin-A, Differin, Tazorac, Atralin, or other retinoids?*

YesNo

If so, please specify and provide date of last dose:

Are you taking antibiotics, birth control, or hormone replacements?*

YesNo

If so, please specify and provide date of last dose:

Do you have AIDS, Lupus, or other chronic condition(s) that may compromise the skin barrier?*

YesNo

If so, please specify:

Do you have any allergies including allergies to wax or latex?*

YesNo

If so, please specify:

Have you used a tanning bed or experienced prolonged sun exposure within the past 24 hours?*

YesNo

Do you have rosacea, eczema, psoriasis, cracked or open skin, severe varicose veins, or any skin sensitivities?*

YesNo

If so, please specify: