Dermaplaning/Facial Consent Form

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Consent and Waiver for dermaplaning and facial services with dhesthetics

Email *

Client Information

General information required for liability purposes.

First & Last Name *

Phone Number *

Address *

Date of Birth (Used for special promotions😉) *

YYYY

Are you over the age of 18? *

Yes

No (parental consent needed if under 18)

Do you consent to receiving emails from dhesthetics? *

Yes

No, do not subscribe

How did you find out about dhesthetics? *

Instagram/Facebook

Google Search

Referred by a friend

Other:

General Information & Consultation

Have you been dermaplaned or had a facial before? *

Yes

Other:

If so, where was it done? What did you like/not like about that experience? (This is simply used to help me understand what you're looking for to give you the best experience possible!) *

When is the last time you had a facial or dermaplaning? *

Service Consent & Waiver

I have read & initialled this consent form & understand the risks & benefits explained in it. *

I understand

I have had the opportunity to ask questions regarding this procedure. *

I understand

I consent to treatment & I assume all responsibility for the risks described above. *

I understand

I consent that I am above the age of 18. *

I understand

The information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition. *

I understand

I agree that if any pictures are taken of my face that they may be posted to dhesthetics Instagram/Facebook or website page & that I will be tagged where/when possible. *

I consent

I do not consent

I verify that I have read and understand the above statements and fully agree to them all. *

Yes

Policy Consent

I understand that any deposit provided to dhesthetics for services is NON-REFUNDABLE. The deposit may be transferred to a new appointment time if reasonable notice is given for cancellation. *

I understand

I understand that if I no-show an appointment or cancel with less than 48 hours notice, 50% of my appointment total is due prior to re-booking. *

I understand

I understand that I must provide 48+ hours notice when rescheduling a full set appointment. I understand that if I reschedule my appointment with less than 48 hours notice I will be charged a rescheduling fee of $50. *

I understand

I understand that I must provide 48+ hours notice when rescheduling a fill appointment. I understand that if I reschedule my appointment with less than 48 hours notice I will be charged a rescheduling fee of $20. *

I understand

I understand that any service rendered, completed and paid for in full by dhesthetics is NON-REFUNDABLE. *

I understand

I verify that I have read and understand the above policies and that they will apply to ALL future appointments and I agree. *

Yes

Medical Form

Do you have any allergies? PLEASE LIST ALL ALLERGIES *

Yes

Other:

Have you taken Accutane or any other form of acne medication whether topical or internal in the past year? *

Yes

Are you using Retin-A, Differin or Renova? *

Yes

Are you taking any medication or using any topical treatments that make you photosensitive? *

Yes

Are you using Retinol, Vitamin C, or any type of chemical peel? If yes, please specify what and when the last time it was used? *

Yes

Other:

Do you frequent tanning beds? If so, when was the last time you used one? *

Yes

Other:

Are you currently sunburnt, or had a sunburn in the last 30 days on your face? *

Yes

Other:

Are you diabetic? *

Yes

Other:

Have you shaved, used a peel, waxed or aggressively exfoliated your face within the past 7 days? *

Yes

Other:

Have you received Botox or fillers within the past 14 days? *

Yes

Other:

Do you currently have or have had any of the following medical conditions that could compromise your skin and/or the service being offered?

AIDS/HIV

ECZEMA

PSORIASIS

COLD SORES

FEVER BLISTERS

HEPATITIS

HERPES

VARICOSE VEINS

CANCER

If you are using any of the following medications, you cannot be dermaplaned today: Accutane, Renova, Tretinoin, Adapalene, Alustra, Avage, Isotretinoin, Avita, Differin, Retin-A, Tazarotene *

I am not using any of the above medication

I am using one or more of the above medications and understand that I will not be able to be waxed

You may experience skin sensitivity/thinning from dermaplaning which can result in skin lifting from the following: Sunburnt skin, Pregnancy, Menstration, Retinol, Antibiotics, certain medical conditions or other medications not listed above. *

I understand

Client Consent

The information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition. *

I affirm

Cannot affirm

This agreement will remain in effect for this procedure and all future dermaplaning/facial procedures conducted by Danielle (dhesthetics). I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign a physical form in person prior to treatment. *

I affirm

Cannot affirm

Please type your full name below to be used as your official signature for this document * *

A copy of your responses will be emailed to the address you provided.

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