Dermaplane

Skin Deep Med Spa, PLLC

1212 Wildwood, Suite A & B, Jackson, MI 49202

517.990.9088 - skindeepspajackson.com

Please complete this form thoroughly and answer the questions honestly.

Name*

First NameLast Name

Date*

Date

Date of Birth*

Date

Phone Number*

Area CodePhone Number

By selecting YES to any or each of the below questions &/or statements I am indicating that I fully understand the question &/or statement and I agree with an affirming YES to it’s accuracy as it pertains to me &/or my treatment.

I understand dermaplaning is the process of removing superficial layers of dead skin from the skin's surface by the use of a sterile blade while removing the villas hairs.*

YESNO

I understand that results may not be seen in a single treatment. The ideal plan of treatment is to have one dermaplaning treatment and continue with treatments as directed by my Esthetician.*

YESNO

I acknowledge that if I fail to use minimal sunscreen (SPF 30) and fail to follow the direction of it's use, I will be more susceptible to sunburn, sun damage and hyper-pigmentation. I also acknowledge that I should avoid excessive sun exposure especially between the hours of 10am - 2pm.*

YESNO

I understand the importance of following post treatment home care as directed by my Esthetician.*

YESNO

I understand there maybe unforeseen risk(s) with dermaplaning such as cutting, scraping, or abrading the skin with the blade*

YESNO

I agree that I was given the opportunity to ask questions and that any questions I asked have been answered to my complete understanding and satisfaction.*

YESNO

I am satisfied with the information provided to me regarding dermaplaning and I agree to have the procedure performed on me.*

YESNO

Have you received fillers or Botox within the last 7 days?*

YESNO

Have you used Retinol within the last 7 days?*

YESNO

*Is there anything that we should be aware of before your dermaplaning procedure?

In signing this form, I acknowledge and testify as the following.

All information I have given both written &/or verbally, is true to the best of my knowledge and it is my sole responsibility to inform &/or update Skin Deep Med Spa, PLLC as to any changes in my health status &/or treatments rendered or to COVID-19. I further hereby knowingly consent to receive treatment from Skin Deep Med Spa, PLLC.

I understand the follwing cancellation policy:I understand the following cancellation policy: Cancellation of appointments with less than a 24-hour notice are charged a cancellation fee of 50% of the missed service. Spa Packages and Spa Parties will need to give a 48 hour notice. The credit card on file is charged a fee of 100% of the missed service and will be required to place a nonrefundable deposit to schedule future appointments. Two no shows in a 12 month period will result in termination of our practice.

Note: All prices are subject to change without prior notice. Skin Deep Med Spa PLLC.

By signing this form, I hereby release, hold harmless, waive, discharge, and covenant not to sue Skin Deep Med Spa, PLLC, its directors, oﬃcers, employees, volunteers, and agents with respect to any liability for any injury, loss, and/or damage (including, but not limited to, illness or death) that I may sustain related to services &/or treatments rendered. I further hereby knowingly consent to receive treatment from Skin Deep Med Spa, PLLC

Date*

Date

Signature*

Parental Signature if under the age of 18 years old.

DERMAPLANE TREATMENT FORM

PHOTO RELEASE FORM