Client Form

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Name

Birth Date

Address

Address Line 1

City

State

Zip Code

Phone

Emergency Contact: (Name)

Emergency Contact: (Phone Number)

How would you describe your skin?

Oil
Dry
Combination
Sensitive

If yes, what are your Concerns?

Are you currently under the care of a physician?

Explain

How do you heal after an acne breakout, cut or scratch?

No Scar
Red
Brown (PH)

Do you smoke?

If yes, date of last cold sore?

Do you have an allergy to Latex?

The answers I have provided are true and correct to the best of my knowledge

Client Signature

Date

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, and 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.

Client Initials:

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.

Client Initials:

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.

Client Initials:

Questionnaire Consent
I understand, have read and completed this questionnaire truthfully. 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 (skinwithdrea) and/or the technician/esthetician/skincare professional (Ana Karen) from liability and assume full responsibility thereof.

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