Dermaplaning Consultation Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Person Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit 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 that Dermaplaning is the process of removing superficial layers of dead skin cells and vellus hair on the skin’s surface by use of a sterile blade. I also understand this procedure removes most, not all vellus hair (peach fuss)
*
I consent
I am not using Renit A, Retinal, or other vitamin A ( Retinal derivatives) products, Tretinoin also products containing Alpha Hydroxy Acids (AHA) or Beta Hydroxy Acids (BHA) and have been off these products for at least 5 days prior to treatment.
*
I’m not using
I’m using (will have to reschedule)
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 Strongly recommended.
*
I consent
I understand that any facial injections should be avoided 10 days before this treatment.
*
I consent
I have been advised not to exercise after my treatment, take steamy showers, go in a sauna or steam room for at least 24 hours after 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 consent
Do you consent to photos/ videos to be taken of your treatment and or treated areas to be used for documentation and or advertising?
*
I consent
No
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If necessary:
Parent/ Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: