Dermaplaning Consultation Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Person Name

First NameLast Name

Have you ever had a dermaplaning facial preformed by a professional?

IF yes, when was the last time you had a dermaplaning facial?

Date

In the last 48 hours, have you had a peel, microdermabrasion, or tanned?

What is your skin type?

Are you sunburned on your face right now?

Do you have any allergies?

Other

Please list all your allergies/allergens.

I understand the possible side effects include but are not limited to: skin tightness, mild to moderate redness, mild flaking, possible nicks

I understand this procedure removes most, not all vellus hair (peach fuzz)

I understand the possible side effects include but are not limited to: skin tightness, mild to moderate redness, mild flaking, possible nicks

I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage, climate, etc.

I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment and the use of a daily sun block protection is mandatory

I understand that any facial injections should be avoided 10 days before this treatment. I am not using Retin A, and have been off Retin A for at least 3 days prior to treatment. I will call my practitioner if I have any questions or concerns about my treatment

I have been advised not to exercise after my treatment.

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-care instructions. Prior to receiving any treatment, I have been candid in revealing any condition that may have bearing on this procedure. I am over 18 years of age..

Signature

Date

If necessary:

Parent/ Guardian Signature

Date