Dermaplaning Consultation and Waiver Form

  • Client Consultation Form

  • Personal/Medical History Form

    To ensure you receive the most appropriate Dermaplaning treatment, please complete the following questionnaire. All information provided will remain strictly confidential.

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us*

  • Medical History

  • Are you pregnant or breastfeeding?*
  • Are you under treatment for any condition or injury?*
  • Are you currently taking any medications?*
  • Do you currently use Retin-A, Accutane or similar products?*
  • Do you currently have (check any that apply):*
  • Are you currently under the care of a physician for any condition?*
  • Are you currently taking any prescription or over-the-counter medications?*

  • DERMAPLANING CONTRAINDICATIONS

  • A contraindication is a condition or factor that may make a client unsuitable for dermaplaning due to health risks or the possibility of adverse outcomes. Please consult with your technician before the procedure if any of the following apply to you:

    Not Recommended for Clients Who Are or Have:

    • Pregnant or breastfeeding (some providers may still proceed with caution)
    • Active acne, cysts, or breakouts in the treatment area
    • Open wounds, cuts, abrasions, burns, or active skin infections (e.g., impetigo, herpes simplex/cold sores)
    • Recent facial surgery or cosmetic procedures (within the past 2–4 weeks)
    • Currently using Retin-A, Accutane (within the last 6 months), or other strong topical exfoliants
    • History of keloid scarring or poor wound healing
    • Active eczema, psoriasis, or rosacea flare-ups
      Very sensitive skin or easily irritated skin
    • Had Botox, fillers, microneedling, chemical peels, or laser treatments within the past 2 weeks
    • Taking blood thinners or medications that increase skin sensitivity
    • Any condition causing involuntary facial movements (e.g., Bell’s Palsy, facial tremors)
    • Autoimmune skin disorders (e.g., lupus, scleroderma)
    • Post-chemotherapy or radiation recovery
    • Use of topical steroids or other medications that thin the skin
    • Severe allergies to topical skincare products


    Please disclose any medical conditions, allergies, medications, or recent cosmetic procedures to your technician before your appointment. Your safety and the effectiveness of dermaplaning depend on open and honest communication.

     

    PRE-TREATMENT ACKNOWLEDGEMENTS
    -I understand and agree to the following:
    -I will avoid using retinoids, AHAs, BHAs, or exfoliating products for at least 5 days before treatment.
    -I have disclosed all medications, medical conditions, and skincare products.
    -I have not had chemical peels, microneedling, waxing, or laser treatments on the treated area in the last 7–14 days.
    -I will notify my technician of any changes to my health or skincare routine before future treatments.

     

  • AFTERCARE

  • DERMAPLANING AFTERCARE INSTRUCTIONS
    To ensure optimal results and minimize the risk of irritation or complications, please carefully follow the aftercare instructions below:

    • Avoid direct sun exposure and wear SPF daily for at least 72 hours
    • Do not wear makeup for 6–12 hours after treatment
    • Avoid exfoliants, retinols, or active acids for 3–5 days
    • Do not use hot water; cleanse with lukewarm water only for 24 hours
    • Avoid sweating, saunas, hot tubs, or intense exercise for 24–48 hours
    • Keep your skincare simple—use only gentle cleanser and moisturizer
    • Avoid waxing, threading, or facial hair removal for 48–72 hours
    • Do not swim in chlorinated or saltwater pools for at least 48 hours
    • Do not pick, scratch, or rub your face post-treatment

  • ACKNOWLEDGMENT

    DERMAPLANING CONSENT FORM AND RELEASE FORM

  • Please read each statement carefully. By checking each box, you confirm that you understand and agree to the statement.

  • I,            am 15 years of age, and understand that a parent or legal guardian must be present at the appointment and provide their signature prior to receiving the Dermaplaning treatment.

  • Date*
     - -
  • Should be Empty: