1. Dermaplaning Pre-Treatment Form
Please fill this in prior to your appointment
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Email *
*
Address *
Email *
Occupation *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Referred by *
Emergency Contact (Name/Relationship/Phone) *
Absolute Contraindications *
YES
NO
Accutane or other similar medication
Autoimmune disease, HIV, lupus, hepatitis, scleroderma
Active infection in the treatment area
Melanoma or lesions suspected of malignancy
Active Sunburn
Pregnancy
Breastfeeding
Epilepsy
Relative Contraindications *
YES
NO
Anticoagulants therapy (use lower settings)
Very thin skin
Other Aesthetic Treatments: Botox: wait 5-7 days; Fillers: wait 7-10 days; Peels: wait 30 days
Laser Treatments: wait until lesions heal & swelling & redness is resolved
Skin Test (Select if/where appropriate) *
Excellent
Good
Fair
Poor
Moisture content
Muscle tone
Elasticity
Skin's healing ability
Skin Test (Select if/where appropriate)
High
Medium
Low
Sensitivity
Clear selection
Skin Test (Select if/where appropriate)
Fair
Medium
Dark
Olive
Skin tone
Clear selection
Skin Test (Select if/where appropriate) *
Good
Normal
Poor
Circulation
Skin Test (Select if/where appropriate) *
Fine
Dilated
Comodones
Malia
Pores
Which of the following best descibes your skin type? *
Required
Do you have any special skin problems or concerns pertaining to your face or body? Please Specify: *
If YES please specify:
Have you ever had chemical peels, laser or microdermabrasion? *
In the last month?
Clear selection
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A products? *
If YES Describe:
Have you used Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A  products in the last 3 months? *
Have you used any acne medication? *
If YES When & Which medication?
What skin care products are you currently using? (List brand where known)
What areas of concern do you have regarding your: Skin: (Please check any that apply and explain) *
Required
Eyes:
Lips:
Have you ever had an allergic reaction to any of the following? (Please check any that apply):
If yes, please explain:
What SPF do you use on your face?  How often/when?
What SPF do you use on your body?  How often/when?
Have you had any recent tanning bed or sun exposure that changed the colour of your skin? *
If YES please specify
Have you experienced Botox, Restylane or Collagen injections? *
If YES please specify
CONSENT FORM
What to expect:

Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.

You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.

Client experiences may vary. Some clients may experience a delayed onset of these symptoms.

You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.

The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.
1. I acknowledge that my skin might experience temporary irritation, tightness, or redness, which usually dissipates within 72 hours depending on skin sensitivity.     *
2. I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.     *
3. I have disclosed my history of allergies above and I acknowledge that I may experience an allergic reaction. *
4. I hereby agree to have the treatment performed and agree to follow all pre-and post-treatment instructions. *
5. I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre and post-treatment. *
6. I acknowledge that I have answered all questions truthfully and completely. *
7. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician and /or skincare practitioner per and post the treatment. *
8. I release the service provider, management, and staff from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products. *
9. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name will not be used to identify these photographs without my written approval. (We will mask your eyes so people won't know who it is) *
By signing below, I certify that I have read and fully understood the contents of this consent form, and that the information I provided above are complete, accurate, and up-to-date to my knowledge.
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