Dermaplaining - Consultation & Treatment Waiver

Dermaplaining - Consultation & Treatment Waiver

Caribbean Day Spa
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Please check all that apply (Counter Indications):

AIDSHemophiliacOn Blood ThinnersDiabeticHerpetic BreakoutPre or Post ChemotherapyThin SkinSun or Wind BurnGrades 2, 3, or 4 AcneDeep WrinklesLess than one week since a chemical or micro peelOpen Wounds or Abrasions
What types of exfoliation treatment have you had, when was the last one, how did your skin react?
Do you use Retin-A:

YesNo
Are you currently tanning in a salon or outdoors?

YesNo
Is your skin sensitive to any of the following:

SunHeatCold
What are your skincare goals or concerns, what would you like to improve?
Do you have any other questions or concerns that you would like to address?
Dermaplaining Release Waiver
I understand that dermaplaning is the process of removing superficial layers of dead skin cells on the skin’s surface by the use of a sterile stainless steel surgical blade.*

AgreeDisagree
The process of dermaplaning has been explained to me by my Skin Care Therapist and I have had the opportunity to ask all my questions.*

AgreeDisagree
I understand, for optimum results, the importance of following the prescribed home care and that a series of treatments is necessary to manifest changes in skin health and age management. I can have weekly treatments if desired. Monthly treatment is recommended for maintenance once optimal results are achieved.*

AgreeDisagree
I understand that there may be unforeseen risk with dermaplaning such as nicking, scraping, or abrading the skin with the blade.*

AgreeDisagree
I am satisfied with the information provided to me regarding dermaplaning and agree to have the procedure performed on me.*

AgreeDisagree
I agree to wear sunscreen while in the sun when I am being treated with dermaplaning.*

AgreeDisagree
I understand that combining a chemical peel with dermaplaning is considered an aggressive treatment and will be done only by the discretion of my Skin Care Specialist based on my consultation, skin type, and overall skincare goals.*

AgreeDisagree
I have been forthright and have answered all question truthfully to my knowledge.*

AgreeDisagree
I consent to receiving dermaplaning treatment from my Skin Care Specialist being fully aware of the benefits and risks.*

AgreeDisagree
I have turned my cell phone off and it will not ring/vibrate during my treatment.*

AgreeDisagree
In consideration for receiving services with Caribbean Day Spa, I hereby release, waive, discharge, and covenant not to sue my Skin Care Specialist or the business that employs her Skin Care Specialist from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, or injury that may be sustained by me or property belonging to me, whether caused by negligence or otherwise, while participating in such activity. I am fully aware of the risks involved and hazards connected with dermaplaning treatment and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in such an activity, whether caused by the negligence or otherwise.
Signature
Signed Date

MonthDayYear
Date
Enter the message as it's shown*
Should be Empty:

Dermaplaining - Consultation & Treatment Waiver

Dermaplaining Release Waiver