CLIENT INFORMATION Gender Address
Would you like to be added to our email list for news and exclusive offers? MEDICAL HISTORY
MEDICAL HISTORY
CONSULTATION FORM Any known allergies? Are you currently taking any blood thinning drugs? Have you had chemotherapy/radiation within the last 6 months? Any previous surgeries, including plastic surgery? Are you currently under a doctor’s care? SKIN CARE
SKIN CARE What is your skin type? Your exposure to the sun? What type of foundation do you wear? How does your skin heal? Do you burn easily in moderate sun?
CONSULTATION FORM SKIN INFORMATION
Have you ever used acne medication e.g. Isotretinoin/Accutane? Do you have permanent or semi permanent makeup? Any recent injectables, chemical peel, waxing or laser treatment? Have you used Retin-A, Renova, AHA's or Vitamin A derivative products in the past 3 months? Have you had any facial or dermatology services in the past 30 days? Do you currently have a sunburn? Do you smoke? Are you currently using a product that contains any of the following ingredients? MEN ONLY
Do you suffer from ingrown facial hair? Experience razor burn? What is your current shaving system? By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities toward Immaculate Complexion, and any of their associates for any injury or damages incurred due to any misrepresentation of my health history.
SCOPE OF PRACTICE The procedure
DERMAPLANING INFORMED CONSENT POSSIBLE RISKS AND SIDE EFFECTS Redness, peeling and swelling Scarring Changes in skin color Infection
MEDICAL CONDITIONS
Please initial:
DERMAPLANING INFORMED CONSENT DISCLAIMERBy signing below, I hereby acknowledge that I understand the nature of the procedure to be performed, the contraindications, side effects, risk, and complications. I acknowledge that I have been given the opportunity to ask any questions regarding the procedure, and these questions have been answered to my satisfaction. I understand the pre and post care instructions and how crucial they are for the success of dermaplaning treatments. By not following the pre and post care instructions, I understand side effects and complications may occur. Although good results are expected, there is no guarantee on the results that may be obtained. I hereby give my unrestricted informed consent for the procedure and subsequent treatments. I hereby release [YOUR COMPANY NAME HERE], and any of their associate from liability associated with this procedure. I am aware this is a cosmetic procedure and I am fully responsible to pay for the entire amount charged. I understand no refunds for any treatment may be rendered, regardless of the results. I understand it is my responsibility to inform the office staff of any medical changes that have occurred, including any contraindications to the list above.
PRE-TREATMENT INSTRUCTIONS GENERAL PRE-TREATMENT SKINCARE RECOMMENDATIONS
POST-TREATMENT INSTRUCTIONS
Your skin might be red, swollen and slightly tender after the dermaplaning procedure. You may also experience some peeling. This is normal for the first few days. If you notice swelling lasts longer than a week or worsens, contact your healthcare provider
Photo & Video Release Form
I,
hereby grant and authorize Immaculate Complexion the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, videos and /or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print and digital communications, without payment or any other consideration.
This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered.I waive any rights to royalties or other compensation arising or related to the use of the photograph or recording.
Cancellation Policy
Our goal is to provide quality care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy.I have read and fully understand the above Appointment Cancellation Policy and agree to be bound by it's terms. I agree to pay the cancellation fee in the event of a missed appointment.
