Dermaplaning Consultation Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person Name
First Name
Last Name
Have you ever had a dermaplaning facial preformed by a professional?
Yes
No
IF yes, when was the last time you had a dermaplaning facial?
-
Month
-
Day
Year
Date
In the last 48 hours, have you had a peel, microdermabrasion, or tanned?
Yes
No
IF YES, We will need to schedule your appointment for another day!
What is your skin type?
Oily
Dry
Combination
Sensitive
Are you sunburned on your face right now?
Yes
No
IF YES, we will need to schedule you appointment for another day when your skin is healed
Do you have any allergies?
Yes
No
Other
Please list all your allergies/allergens.
I understand the possible side effects include but are not limited to: skin tightness, mild to moderate redness, mild flaking, possible nicks
I consent
I understand this procedure removes most, not all vellus hair (peach fuzz)
I consent
I understand the possible side effects include but are not limited to: skin tightness, mild to moderate redness, mild flaking, possible nicks
I consent
I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage, climate, etc.
I consent
I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage, climate, etc.
I consent
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
I consent
I understand that any facial injections should be avoided 10 days before this treatment. 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
I consent
I have been advised not to exercise after my treatment.
I consent
I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-care instructions. Prior to receiving any treatment, I have been candid in revealing any condition that may have bearing on this procedure. I am over 18 years of age..
I consent
Signature
Date
-
Month
-
Day
Year
Date
If necessary:
Parent/ Guardian Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: