Dermaplaning Consultation & Consent Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Emergency Contact Name & Number:
How did you hear about us?
Referral by Someone Social Media Website Walk-in Other
Medical History
Please check all that apply:
Diabetes Heart condition High/Low blood pressure Epilepsy or seizures Autoimmune disorder Hormonal imbalance Pregnancy or nursing Recent surgery (within 6 months) Blood-thinning medications
Allergies (list)
Medications (especially Accutane, Retin-A, antibiotics): _
Other conditions we should know about:
Skin History & Contraindications
Please check any that apply within the last 14 days:
Sunburn Waxing or sugaring Chemical peel Laser treatment Botox or fillers Active acne lesions or cold sores Open wounds or infections Open wounds or infections Skin conditions (eczema, rosacea, psoriasis)
Do you have a history of keloid scarring or hyperpigmentation?
Yes No
Are you currently using any prescription skincare (topical or oral)?
Yes No If yes, please list:
Have you had dermaplaning before?
Yes No If yes, when?
Treatment Goals & Expectations
What are your primary concerns?
Dull skin Peach fuzz Uneven tone Congestion Texture Other If Other, please describe:
What are you hoping to achieve with dermaplaning?
Client Acknowledgement & Legal Consent
I, the undersigned, understand that dermaplaning is a non-invasive skin rejuvenation procedure using a sterile surgical blade to gently exfoliate the surface of the skin and remove vellus hair (“peach fuzz”).
I understand and agree to the following:
This treatment may result in minor redness, sensitivity, or small nicks to the skin.
The procedure is not recommended for clients with active acne, certain skin conditions, or those on specific medications.
I have disclosed any and all known medical conditions, skin disorders, allergies, and medications that could affect the outcome of this treatment.
I understand that results vary based on individual skin conditions, and that multiple treatments may be necessary for optimal results.
I agree to avoid direct sun exposure, exfoliating agents, and harsh products for at least 72 hours post-treatment.
I acknowledge that no guarantees have been made regarding results, and I release Derma Direction and my esthetician from any liability should any unintended reactions occur, provided proper procedures were followed.
Yes, I give my full, informed, and voluntary consent to receive dermaplaning services from a licensed esthetician at Derma Direction.
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