Dermal Planning Consent Form – Celebrity Skin Studio

Today's Date*

Name*

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Current Age*

If you are a minor, in addition to this form, you must fill out a General Intake & Waxing consent form, including the parental consent portion. This form is located on the website under the FORMS tab.

Please enter a number from 1 to 100.

What is Dermaplaning?

Dermalplaning is a form of manual exfoliation. A sterile blade is stroked along the skin at an angle to gently “shave off” deadskin cells from the epidermis. Dermaplaning also temporarily removes the fine vellus hair of the face, leaving a very smooth surface. As with any type of exfoliation, the removal of dead skin cells allows home care products to be more effective, reduces the appearance of fine lines, evens skin tone and assists in reducing milia, closed and open comedones, and minor breakouts associated with congested pores. It also allows for better product penetration. Dermaplaning can be an effective exfoliation method for clients that have couperose (tiny blood vessels near the surface of the skin), sensitive skin or allergies that prevent the use of microdermabrasion or chemical peels. Due to the contours of the face, certain areas of the face (such as the eyelids and nose) are not treatable using this method.

What to Expect

You may experience some flaking between sessions. Contact yout esthetician if you have any concerns. More sensitive skin may experience some redness. Dermaplaning may cause minor superficial abrasions or nicks. After your treatment wear SPF and avoid Tanning beds and direct sun exposure. The majority of clients receive noticeable, satisfactory to above average results with a series of treatments and a commitment to a daily skin care regimen. However, this outcome cannot be guaranteed as maximum results are highly dependent on age, cumulative sun exposure, health, lifestyle, genetic traits, general skin condition, and willingness to follow recommended protocols. Dermaplaning is not intended for dark thick hair.

Health History

Please check if you have any of the following conditions*

Check all that apply, if none, click none of the above

Active Cold Sores
Hemophelia
Prolonged Bleeding
Hepatitis
Lupus or any autoimmune disease
None of the Above

Do you take any blood thining medication?*

Yes
No

Do you take Aspirin or Ibuphofen on a regular basis?*

Yes
No

LIst any vitamins or suppliments you take. If none list N/A*

Please Read and check the box below*

I understand that to acheive the best results I should follow the home care recommendations of my esthetician.

I understand and agree to the above

BEFORE your treatment: Discontinue use of Retin A, Retinols, Vitamin A creams, Alpha Hydroxy Acids and topical medications for 3-5 days before your treatment. Arrive with cleansed skin if possible. Avoid Sun and Wind exposure several days before your appointment as compromised skin can not be treated. If you have an active coldsore or skin infection you will need to reschedule.

AFTER your treatment: Avoid activities causing you to perspire the day of your treatment. Use Sunscreen. Because this is an exfoliating procedure, wait a couple of days before resuming at home exfoliation.

Consent*

I understand the pre and post treatment instructions and agree to follow the directions and recommendations of my esthetician.

Consent for Treatment and Liablity Waiver*

I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform treatments/procedures and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand 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 been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.

By checking the box and signature below, I agree to Consent for Treatment and Liability Waiver

Signature*

Date*