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Dermaplaning client waiver


Dermaplaning will gently exfoliate and eliminate surface layers of dead skin cells and unwanted vellus hair (peachfuzz) and will prime skin for our professional enzyme or acid peel. Professional enzymes or acid peels dramatically diminishes the appearance of discoloration,while smoothing texture and renewing the appearance of pores, to restore a brighter, more clarified skin tone. For optimal results, a seriesof 4-6 treatments every 4 weeks is recommended.

Risks / Side effects
All things considered, Dermaplaning is very safe.
- Of course, bleeding is possible as the treatment involves the use of a sharp surgical blade. As with your own shaving experiences in theshower, cuts are extremely rare and more annoying than painful.
- Makeup may be applied after Dermaplaning, in fact you may note that your makeup glides on and sits much better on your face after asession than before.
- Your therapist will take every precaution to ensure that your skin is well hydrated and calm following each session. However, you mayexperience excessive dryness or even some peeling between sessions, which may or may not be normal.
- More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.
- Dermaplaning may cause minor superficial abrasions which may not appear until a day or two following your treatment. If this shouldoccur, please contact us so that we can arrange a post-treatment follow up with you.
- After your treatment, SPF 30+ MUST be worn at all times.
- Always seek medical advice if you have any concerns or complications, as well as informing us.

Results
The majority of our clients receive noticeable, satisfactory, above average results with a series of treatments and a commitment to a dailyskin care regimen. However, this outcome cannot be guaranteed as maximum results are highly dependent on age, cumulative sunexposure, health, lifestyle, genetic traits, general skin condition, and willingness to follow recommended protocols. Be aware that manychanges may occur deeper within the skin over time. To continue the maintenance of your skin after you complete your treatment(s), yourpractitioner may inform you of other preventive treatments that may benefit your skin and help with management of your skin.


Pre-treatment Instructions


- Please discontinue products containing any exfoliating agents (retinoic acid, tretinoin, retinol, benzoyl peroxide, glycolic acid, salicylicacid, astringents, etc.) at least 72 hours before treatment.
- A history of herpes or cold sores may require a course of antiviral medication pre and post treatment.
- Your provider will recommend appropriate products to help enhance results and/or minimize potential side effects.
- In regards to Isotretinoin (Anti-Acne), also known as Accutane, you can only be treated if the medication has not been taken within thelast six months.

Maintenance Instructions


- You may experience slight redness and swelling, which should resolve within 24 hours.
- Apply SPF 30 and UV Ray protection daily post treatment.
- Mineral make-up can be worn immediately following treatment.
- Avoid heat, saunas, hot tubs and all sweat-inducing activity for 24 hours; this includes exercise of any kind.
- Avoid products containing any exfoliating agents (retinoic acid, retinol, tretinoin, retinol, benzoyl peroxide, glycolic acid, salicylic acid,astringents, etc.) for 7 days post treatment.
Skin Disease/Skin Lesions
Chemotherapy or Radiation
Eczema or Dermatitis
- You may resume your regular skin care routine (excluding the points made above) 24 hours after treatment.

 

 

 

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

First Clients Signature*
Second Clients Name

First Name*

Middle Name

Last Name*
Second Clients Date of Birth*
Second Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Third Clients Name

First Name*

Middle Name

Last Name*
Third Clients Date of Birth*
Third Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Fourth Clients Name

First Name*

Middle Name

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Fifth Clients Name

First Name*

Middle Name

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Sixth Clients Name

First Name*

Middle Name

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Seventh Clients Name

First Name*

Middle Name

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Eighth Clients Name

First Name*

Middle Name

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Ninth Clients Name

First Name*

Middle Name

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Tenth Clients Name

First Name*

Middle Name

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Parent or Guardian's Email Address

Email*

Confirm Email*
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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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Please see if any of the following apply

Active Acne

Any Active Infections

Any Raised Lesions

Any Recent Chemical Peel Procedures

Botox or Cosmetic Filler Injections within 2 weeks

Family History of Hypertrophic scarring or Keloid Formation

Hemophilia

Hormonal Therapy that produces thick Pigmentation

Moles

Oral Blood Thinner Medications

Pregnancy

Recent use of topical agents such as Glycolic Acids or AHA or Retin-A

Rosacea

Scleroderma

Skin Cancer

Sunburn

Facial Tattoos

Telangiectasia/Erythema

Coarse/dark facial hair

Diabetes

Ulcer Disease

Use of Accutane within the last year

Vascular Lesions

If you have any of the above conditions please give details:

Parent or Guardian's Signature*
Electronic Signature Consent*
 Please read the following information carefully and to your understanding and acceptance. I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness of the skin, irritation and dryness. Additionally, risks to the skin can occur due to the sharp surgical blade. Clients will be notified and the area will be treated if necessary. The hair is expected to grow back blunt-ended. New hair will not appear darker or denser, however I do understand that any hormonal imbalance that may be present within my anatomical system can alter my normal hair growth pattern. I understand that the sensation and penetration of the peel will be enhanced which may cause skin irritation, mild discomfort and tenderness. I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release the practitioner against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.


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