Client Forms

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.

YOUR SKIN CARE

What skin care products are you currently using? (List brands if known)

HEALTH HISTORY

LIFESTYLE

FUTURE APPOINTMENTS/CONTACT

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):

Cosmetic History

Health History

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes

your skin. This information will be used by your technician to determine the most appropriate way to approach

your treatment(s):

Please list the products you use regularly:

Cosmetic History

Health History

I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.

What is Dermaplaning?

Dermaplaning is a form of manual exfoliation similar in theory to microdermabrasion but without the use of suction or abrasive crystals. An esthetician grade, sterile blade is stroked along the skin at an angle to gently “shave off” dead skin cells from the epidermis. Dermaplaning also temporarily removes the fine vellus hair of the face, leaving a very smooth surface.

As with any type of exfoliation, the removal of dead skin cells allows home care products to be more effective, reduces the appearance of fine lines, evens skin tone and assists in reducing milia, closed and open comedones, and minor breakouts associated with congested pores.

Dermaplaning can be an effective exfoliation method for clients that have couperose (tiny blood vessels near the surface of the skin), sensitive skin or allergies that prevent the use of microdermabrasion or chemical peels.

Due to the contours of the face, certain areas of the face (such as the eyelids and nose) are not treatable using this method.

What should you expect during your treatment?

As your esthetician, I will perform a thorough skin analysis prior to your first dermaplaning.

If dermaplaning is not appropriate, you will be informed during this session and an alternative treatment may be recommended instead.

If dermaplaning is not contraindicated, maximum results are obtained by participating in a series of treatments plus following a home care regimen.

I will review your current daily regimen and skin care products, advise you on which products you should continue to use, and recommend any additional products or changes to your regimen to enhance your desired outcome.

As your esthetician, I take every precaution to ensure that your skin is well hydrated and calm following each session. However, you may experience excessive dryness or even some peeling between sessions, which may or may not be normal. Always contact me if you have any concerns.

More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours. Dermaplaning may cause minor superficial abrasions which may not appear until a day or two following your treatment. If this should occur, please contact me so that I can do a post-treatment follow up with you.

After your treatment, SPF 30+ MUST be worn at all times. Tanning beds should never be used. You are making an investment in your skin: therefore, it is to your benefit to continue to protect it long after your series of treatments is completed.

Is satisfaction guaranteed?

The majority of my clients receive noticeable, satisfactory to above average results with a series of treatments and a commitment to a daily skin care regimen. However, this outcome cannot be guaranteed as maximum results are highly dependent on age, cumulative sun exposure, health, lifestyle, genetic traits, general skin condition, and willingness to follow recommended protocols.

Be aware that many changes may occur deeper within the skin over time. To continue the maintenance of your skin after you complete your treatment(s), I may inform you of long-term age management programs.

Contraindications

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for dermaplaning treatment and must be disclosed prior to treatment.

• Active acne
• Active infection of any type, such as herpes simplex or flat warts.
• Any raised lesions
• Any recent chemical peel procedure
• Chemotherapy or radiation
• Eczema or dermatitis
• Family history of hypertrophic scarring or keloid formation
• Hemophilia
• Hormonal therapy that produces thick pigmentation
• Moles
• Oral blood thinner medications
• Pregnancy
• Recent use of topical agents such as glycolic acids, alpha-hydroxy acids and Retin-A
• Rosacea
• Scleroderma
• Skin Cancer
• Sunburn
• Tattoos
• Telangiectasia/erythema may be worsened or brought out by exfoliation
• Thick, dark facial hair
• Uncontrolled diabetes
• Use of Accutane within the last year
• Vascular lesions

Post-Treatment/Home Care

Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided. Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure or tanning beds). Although SPF 30+ should already be a part of your daily skin care, after dermaplaning, SPF 30+ must be applied daily to the treated area for a minimum of two weeks. Twice daily cleanse the treated area with a post-treatment cleanser, followed by a serum or treatment cream and follow with SPF 30+ sunscreen.

If you have additional questions or concerns regarding your treatment or suggested home regimen, you will consult your esthetician immediately.

Although every precaution will be taken to ensure your safety and wellbeing before, during and after your LED treatment, please be aware of the following information and possible risks. Please initial:

I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the LED procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Please be aware of the following information and possible risks associated with Microcurrent Treatment. Please initial:

I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the microcurrent procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Please read and initial where indicated.

Micro-needling devices intentionally create very superficial “micro-injuries” to the outermost layer of the skin, inducing the healing process including new collagen production. Micro-needling has been shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger-looking skin. Skin needling treatments are performed in a safe and precise manner with the sterile devices and are normally completed within 30-60 minutes, depending on the selected area.

I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the micro-needling procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

As the parent or legal guardian of

I confirm that I have read and understand all information on the applicable forms for this treatment or service, and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care procedures that are recommended as a result of the treatment.

This form must be signed in person by the parent or guardian at the time of service, witnessed by the esthetician.

Aerobic exercise or vigorous physical activity should be avoided for the first 48 hours.

Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure and tanning beds). If some sun exposure cannot be avoided, first apply sunscreen with an SPF of 30 or greater. Sunscreen (with at least a SPF of 15) should become a part of your daily skin care regimen as your skin will become more sensitive to the sun as a result of this treatment.

Do NOT apply any type of glycolic acid or exfoliation products as this can severely damage or irritate the skin during the entire healing process.

DO NOT peel, rub, or scratch your skin at anytime, whatsoever. This WILL cause damage and compromise your results as well as possibly cause severe scarring.

If you experience painful areas of the face, contact your skin care therapist immediately, especially if you are prone to cold sores. Any blisters that form will need to be reported immediately.

In the event that you may have additional questions or concerns regarding your treatment or suggested home product/post-treatment care, you must consult your therapist immediately.

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):

Cosmetic History

Health History

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.

We appreciate your business. So that we can best serve all our clients, please be advised of these policies.

ARRIVAL TIME

Please aim to arrive 10 minutes before your scheduled appointment time. If you arrive after your scheduled appointment time, it may not be possible to extend the time available for your booked service; if your service is shortened due to your late arrival, you may still be charged the full cost of the service.

CHANGING YOUR APPOINTMENT

24 hours’ notice is required to reschedule or cancel a booked appointment.

I agree to the policies described above.

Skin Classification

Recommended Home Skin Care Products:

Client’s Detail

Skin Classification

Signature

By signing below, I acknowledge that I have read, understood, and consent to the above checklist and the Hydrafacial procedure.