Phases Esthetics Dermaplaning Consent & Acknowledgment
Review the dermaplaning information, answer the health/skin questions, and confirm your consent and aftercare agreement.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Today’s Date / Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Before Treatment
Please answer the following questions honestly. A “Yes” answer does not necessarily mean you cannot receive dermaplaning. It means we may need to discuss your skin, medications, or recent treatments before proceeding.
Active, inflamed, cystic, or pustular acne in the treatment area?
*
Yes
No
Open cuts, sores, abrasions, sunburn, windburn, or irritated/broken skin on the face?
*
Yes
No
Active cold sore, herpes outbreak, or other active skin infection?
*
Yes
No
Active eczema, psoriasis, dermatitis, or another inflammatory skin condition in the treatment area?
*
Yes
No
Recent facial waxing, threading, sugaring, or chemical depilatory use on the treatment area?
*
Yes
No
Recent chemical peel, microdermabrasion, laser treatment, microneedling, or other resurfacing treatment?
*
Yes
No
Recent Botox, dermal filler, or other injectable/facial procedure?
*
Yes
No
Current use of prescription retinoids or other prescription acne medications?
*
Yes
No
Current use of over-the-counter retinol, retinal, adapalene/Differin, exfoliating acids, or other potentially sensitizing skincare products?
*
Yes
No
Previous or current use of isotretinoin/Accutane or a similar oral retinoid?
*
Yes
No
Bleeding disorder, blood-thinning medication, or tendency to bruise/bleed easily?
*
Yes
No
Diabetes that is not well controlled, impaired wound healing, or another condition that may affect healing?
*
Yes
No
History of keloid or abnormal scar formation?
*
Yes
No
Current chemotherapy, radiation, immunosuppressive treatment, or treatment for a condition that may affect healing or immune function?
*
Yes
No
Known allergies or sensitivities to skincare products, adhesives, metals, antiseptics, or topical ingredients relevant to treatment?
*
Yes
No
If you answered Yes to any question above, please explain:
Understanding the Treatment
I understand that dermaplaning uses a sterile, single-use blade to gently remove surface dead skin cells and fine vellus hair.
*
I understand
I understand that possible temporary side effects may include redness, sensitivity, dryness, tightness, irritation, minor breakouts, and occasional small nicks or abrasions.
*
I understand
I understand that every person’s skin responds differently and that results cannot be guaranteed.
*
I understand
I understand that dermaplaning temporarily removes vellus hair and does not cause normal vellus hair to grow back thicker, darker, or coarser.
*
I understand
Aftercare Acknowledgment
I will treat my skin gently and avoid picking, scrubbing, or aggressive exfoliation after treatment.
*
I acknowledge
I will avoid strong exfoliating products, retinoids, and other potentially irritating active products until my skin has returned to normal or as instructed by my esthetician.
*
I acknowledge
I will avoid unnecessary heat, excessive sweating, and prolonged sun exposure immediately following treatment.
*
I acknowledge
I will use gentle skincare and a broad-spectrum sunscreen of SPF 30 or higher daily.
*
I acknowledge
I will follow any additional post-care instructions provided by my esthetician.
*
I acknowledge
Final Consent and Signature
Final informed consent and authorization: Phases Esthetics may postpone or decline treatment at the esthetician’s professional judgment. I voluntarily consent to receive dermaplaning services from Phases Esthetics Louisville LLC.
Client Signature (Type Full Name)
*
First Name
Last Name
Today’s Date / Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: