Dermaplane Consent Form

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect.

• I give permission to my esthetician to perform a dermaplaning treatment

• I agree to be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor exposure, tanning beds, alcohol consumption and/or recreational use of controlled substances, will affect and diminish the effectiveness and result of the treatment.

• I have disclosed to my esthetician any surgical procedures, laser treatments or facial procedures that I have had or intend on having in the future.

• I have not received Botox or fillers within 7 days of this appointment.

• I have not used any form of Vitamin A within the past 5 days and will not use Vitamin A 5 days after the service.

• I have not had any recent chemotherapy or radiation treatments in the past year.

• I have not recently waxed or used a depilatory (such as Nair) on the area being treated today. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters or cold sores.

• I have not had any other peel treatment of any kind within 14 days of treatment. I understand I cannot have another treatment within 14 days of this treatment, whether the treatment is performed at this location or any other location.

• I agree to refrain from excessive sun exposure or the use of a tanning bed while I am undergoing treatment and during the 3 days following the end of the treatment.

• I understand that sun exposure is prohibited while I am undergoing treatment and that the use of sunscreen is mandatory.

• I understand the purpose of this procedure is to exfoliate the outer surface of my skin.

• I understand that the following conditions preclude me from having this treatment currently and verify that none of these conditions apply to me at this time.

  • Broken skin on areas to be treated

  • Sunburn or windburn skin

  • Visible inflammatory or inflammatory lesions

  • Herpes virus (cold sores) on mouth

  • Laser Hair Removal within 6 weeks

  • Use of glycolic acid products

  • Use of Retin-A®, Renova®, retinoids (Vitamin A) in the last 4 weeks

  • Use of Accutane within the last 12 months

  • Active moderate-severe acne

• My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, or pigmentation levels.

• I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complication, I will immediately contact the esthetician who performed the treatment.

• I understand that every precaution will be taken to minimize or eliminate negative reactions such as blisters, redness, or irritation.

• I understand that my esthetician will recommend home care products to work in tandem with the in-clinic treatment. I am willing to follow recommendations by my esthetician for home care.

• In the event of any questions or concerns, I will consult my skin care professional immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I will hold the esthetician harmless from any liability that may result from this treatment. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.