Dermaplaning Consultation Form

Gather a client's skin history and the required authorizations before a dermaplaning session, covering allergies and a signed consent.

Use this template

Name

Nombre

Apellido

Phone Number

Emergency Contact Person Name

Nombre

Apellido

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

Yes No

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

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

Yes No

Are you sunburned on your face right now?

Yes No

Do you have any allergies?

Yes No

Please list all your allergies or allergens.

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

I Agree I Do Not Agree

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

I Agree I Do Not Agree

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

I Agree I Do Not Agree

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

I Agree I Do Not Agree

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

I Agree I Do Not Agree

I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment, and daily sunblock use is mandatory

I Agree I Do Not Agree

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

I Agree I Do Not Agree

I have been advised not to exercise after my treatment.

I Agree I Do Not Agree

I hereby agree to all of the above and consent to have this treatment performed on me. I further agree to follow all post-care instructions and confirm that I am over 18 years of age.

I Agree I Do Not Agree

Signature

Sign here

Date

Parent/Guardian Section (if applicable)

Parent/Guardian Signature

Sign here

Date

Dermaplaning Consultation Form

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