Download Patient Consent for Dermaplaning Treatment I

Patient Consent for Dermaplaning Treatment
I hereby authorize Zanya Spa Salon to perform a Dermaplaning treatment. The goal of Dermaplaning, as in any
cosmetic procedure, is aesthetic improvement, not perfection. I understand that my results may not be perfect.
The number of treatments necessary will vary among individuals and the areas being treated.
Dermaplaning is a highly efficient, safe, physical exfoliation procedure used to clear away dry, dead, superfluous
skin layers using a modified surgical blade designed specifically for this purpose.
I understand that the following side effects or complications may occur:
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Discomfort, Itching, Irritation: is generally minimal and subsides after a short duration
Exisitng blemishes or moles, blood vessels, freckles, and sun spots may become more obvious because
layers of dead skin have been removed
Pigmentation: is rare and usually temporary. Possible permanent changes in the color of skin could occur.
Milia: may occur, but will usually disappear quickly
Redness and swelling: for a period of 2 hours to 7 days
Skin peeling or flaking: for up to 7 days after the procedure
Infection: is extremely unlikely, but may happen
Herpes outbreak in affected individuals: if you are prone, ask your physician for medication
Scarring: very rare
New hair will not appear darker or denser. However, any hormonal imbalance that may be present within my
anatomical system can alter the normal hair growth pattern and cause darker and denser restoration process.
I confirm that I am not currently taking blood thinners, I have not used Accutane or other oral retinoid products in
the past 12 months, and I have not used a topical retinoid (Retin A, Differin, Tazorac) in the past two weeks, I am
not currently taking a medication that causes hair growth as a side effect.
I have informed my skin care provider if I have any of the following conditions: history of pigmentation disorder,
history of keloid scarring, active herpes simplex, recent peels or laser treatments, recent sun exposure,
autoimmune disease, any surgery in the past six months.
I understand the Dermaplaning procedure is a controlled process, but it is not an exact science and the results
cannot be guaranteed. I acknowledge that no guarantee has been made by anyone regarding the results of this
treatment that I have requested and authorized. The technician has provided the information and answered all of
my questions concerning this procedure. I clearly understand the information presented above and will inform my
therapist of any changes in my health and medical condition.
Patient Name (print)________________________Patient Signature__________________________Date________
Witness Name (print)_______________________Witness Signature__________________________Date________