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Bella Fiore Organic Med Spa
Dermaplaning Consent Form

I am not using Retin-A and have discontinued use of this and similar products for at least 3 days prior to this treatment

I understand I am receiving an exfoliation treatment using a sterile surgical blade

I understand this procedure removes most, not all vellus hair (soft peach fuzz)

I understand this treatment is a cosmetic treatment and no medical claims are expressed or made

I understand the possible side effects include but are not limited to: Skin tightness, mild to moderate redness, mild flaking and possible nicks

I have notified my practitioner of my current medications and medical conditions

I understand that prolonged sun exposure or tanning beds is NOT recommended while before or after treatment and the use of sunblock is recommended

I understand that any facial injections should be avoided for 10 days prior to this treatment

I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage etc.,

I have been advised not to exercise after my treatment

I will call my practitioner if I have any questions about my treatment

I am over 18 and further agree to follow all care instructions

November 22, 2019

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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