Dermaplaning | Rammy Rose

Dermaplaning: Online Consent Form

Please fill out the following form.

First name

Last name

Email

Phone

Date of birth

Year

Month

Day

Age

Please check all current and previous medical conditions listed below that apply to you

1. Are you being treated for any other conditions not listed above?

Yes

No

2. Are you using Retinol Cream or Accutane?

Yes

No

3. Are you using any products that contain AHA's or glycolic acids?

Yes

No

4. Have you had any facial piercings or tattoos?

Yes

No

5. Have you had any Botox or fillers within the last 3 months?

Yes

No

6. Have you had any Tanning Services in the last 3 months?

Yes

No

7. Have you ever had any severe facial sun burns within the last year?

Yes

No

Please check each box after understanding each statement

The goal of Dermaplaning is improvement, not perfection. When using Dermaplaning procedures, the number of treatments depends on several factors including but not limited to skin type, skin sensitivities and skin tan

I understand that a sterile surgical blade is used for this procedure, which is held at a 45 degree angle and stroked along the face, very similar to shaving

Although the rarity of such an event, there is a possibility of nicking or cutting the skin. However, the incidence of cutting into the skin is slim, our estheticians are thoroughly trained and have previous experience performing the procedure

I understand that blading of the skin is performed primarily on the face excluding the nose, eyelids, neck, or chest, and may be performed every 3-4 weeks. Blading removes 2-3 weeks worth of dead skin cells.

I acknowledge that I have been informed that blading the skin on the face does not cause the hair to grow back thicker or darker. The structure of the vellus hair (thin, translucent blond hair) is not damaged during the blading and grows back the same. However, becuase the hair is cut, it grows back with a blund edge but the hair has not been physiologically altered

I understand that there is a possibility of the skin to peer or flake after dermaplaning although this is not common, and if peeling does occur, there is no damage to the skin

I understand that all skin types can benefit from dermaplaning. However, the procedure is not recommended for those suffering from severe acne and/or overproduction of the sebaceous glands. The oils from the sebaceous glands need to travel up and connect with the vellus hair. If the hair is removed, then the oils tend to stay below where they are prone to mix with bacterial colineism ultimately stimulating more acne

The treatment fees have been discussed with me and I understand them. We require 24 hours notice if cancellations or a 50% treatment cost will be charged

THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS, READ IT CAREFULLY

I confirm the answers I have given in this form and I have not withheld any information requested by this form
I have been informed of the proper use and equipment for the services I am receiving
I have been advised of all risks associated with the use of equipment required for the services I am receiving. I have been advised of all the risks associated with the services and procedures I will be receiving. I agree to comply with all instructions provided by the operator
I hereby release Rammy Rose Hair & Beauty Ltd its affiliates, officers, directors, agents, employees and contractors from liability for any injury, loss or damage that may result from the use of the equipment or from any services provided or treatment rendered. This release bonds my heirs, successors and assigns.

I declare that the info I’ve provided is accurate and complete.

Signature

Date picker

Please show your filled form to the service provider, without their acknowledgement, this form cannot be submitted, and we will not start the service until the form is submitted

Service Provider Signature

I have checked the client’s form for any contraindications and have consulted with the client what the effects of these contraindications will have during and after the service