DERMAPLANE DISCLOSURE & CONSENT FORM

DERMAPLANE

DISCLOSURE & CONSENT FORM

Page 1 of 2 Serenity Day Spa & Salon, Inc. 11/2021

Dermaplaning is a physical/mechanical form of exfoliation using a specialized dermaplaning blade for the

removal of built up dead skin cells and vellous hair. Following treatment skin will be smoother, softer and

better able to absorb the active ingredients in treatment and home care products.

Please read and initial the following:

_________I understand I am receiving an exfoliation treatment using a sterile surgical blade which removes

most, not all vellus hair (peach fuzz) and as with the use of any sharp instrument, there is the possibility of

nicks or cuts.

_________I understand the results of this treatment may vary due to conditions such as age, condition of skin,

sun damage, climate, etc. and this treatment is a cosmetic treatment in which no medical claims are expressed

or implied.

_________I have read and understood prior to the treatment the benefits and outcome of the service.

_________I understand with ANY beauty service there are inherited risks, including but not limited to allergic

reactions. Understanding potential side effects may include, grazing, abrasions, skin sensitivity or adverse

reactions to products used during treatment.

_________I understand I must follow my aftercare to prevent potential skin irritations and 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 there are contraindications to this treatment, including but not limited to, diabetes

(not controlled by diet or medication), cancer, active acne, bleeding disorders, the inability for blood to

coagulate or the development of keloids following injury. Certain medications including blood thinners, higher

dosages of Aspirin, and Accutane are contraindicated for this treatment due to the possibility of delayed

clotting from a nick or cut. I certify that I am not taking any of the above medications or experiencing any of

the above conditions.

_________I understand that not providing the required information regarding what I do before or after the

treatment may affect the results, and do not hold the Esthetician or Serenity Day Spa & Salon, Inc. responsible.

Please check if you are using any of the following:

 Vitamin A (retinol, retain A, retinyl palmitate)

 AHA’s (Glycolic, Lactic, Malic, Tartaric, Citric, Mandelic acids)

 BHA’s (Salicylic acid)

 Roaccutane

 Skin antibiotics

 Prescriptive skin creams

DERMAPLANE

DISCLOSURE & CONSENT FORM

Page 2 of 2 Serenity Day Spa & Salon, Inc. 11/2021

 Diabetic medications or blood thinners

Please check if you suffer from any of the following:

 Facial skin cancers

 Acne

 Rosacea

 Facial skin tags

 Facial psoriasis, eczema or dermatitis

 Herpes simplex virus

________I give my permission to photograph my face and these photos may be used in her portfolios, as an expert

witness, advertising, or for educational purposes without any present or future payment to me.

________I am 18 years of age or older and have informed the skin care specialist of any physical or psychiatric health

problems that would prevent me from having this procedure performed, and I know of no reason why I should not have

these procedures performed on me. I understand that temporary redness, swelling, bruising and discomfort occur from

this procedure. Possible complications that could occur include, but are not limited to, risk of infection, allergy or

sensitivity to local anesthetics and inconsistent results. I will also seek medical attention as recommended by skin care

specialist if necessary and understand that I am responsible for the full payment of expenses incurred in the event this is

necessary.

This procedure is being performed under standard sanitizing and sterilizing methods as recommended by the Centers for

Disease Control and as required by the State Department of Health. All needles used of are disposed of properly after

each procedure.

In consideration of the skin care specialist providing me with the service requested, I for myself, my spouse, legal

representatives, heirs, and assigns, hereby release, waive and discharge the skin care specialist along with Serenity Day

Spa & Salon, Inc. from liability for all loss of damage on account of or injury to person. I understand several procedures

are necessary to achieve the desired effect and agree to complete my treatments as recommended. Should I not

complete treatments, I will be responsible for any adverse outcome.

I expressly agree that this consent, waiver, and indemnity agreement is intended to be as broad and inclusive as

permitted by the laws in the State of Georgia. I have read this consent and understand all its terms and execute this

release voluntarily, and with full knowledge of its significance. All my questions have been answered satisfactorily prior

to signing of this consent.

Client Signature__________________________________________ Date:__________________

Witness Signature_________________________________________ Date:__________________