Dermaplaning Consent And Release Form

First name

Last name

Birthday

Month

Day

Year

Phone

Dermaplaning is a professional exfoliation treatment that uses a sterile surgical blade to gently remove dead skin cells and vellus hair (peach fuzz) from the surface of the skin. This treatment helps improve skin texture, brightness, product absorption, and makeup application.

Medical History-Please Check All That Apply

Pregnant or Breastfeeding

Active Acne or Cystic Acne

Rosacea

Eczema/Psoriasis

Very Sensative Skin

Open Wounds, cuts, or abrasions

Sunburn or recent excessive sun exposure

Skin infection, rash, or cold sores

History of Keloid Scarring

Autoimmune Conditon

Diabetes

Blood Clotting Disorder

Skincare and Treatment History

Have You Used any of the Following in the Last 7-14 Days?

retinol/Retin-A/Tretinoin

Accutane (within last 6-12 months)

Chemical Peels

Laser or light treatments

Waxing or depilatory creams

Exfoliating acids or scrubs

If Yes Please Explain

Client Acknowledge and Consent

Please Read and check all boxes

I understand the dermaplaning procedure and how it is performed.

I understand dermaplaning does not cause hair to grow back thicker or darker

I understand that results vary and no guarantees can be made.

I understand possible temporary side effects may include redness, sensitivity, dryness, tightness, tingling, or mild irritation

I understand there is minimal risk of nicks or superficial abrasions .

I confirm I have disclosed all medical conditions, medications, and skincare products I am using.

I understand that failure to disclose information may increase the risk of adverse reactions.

I agree to follow all post-treatment care instructions provided.

Contraindications

Active acne, open wounds, sunburn, Active cold sores, herpes or impetigo, skin infections, eczema, psoriasis, dermatitis, rosacea, inflamed or compromises skin, recent bruising or broken capillaries, suspicious lesions or skin growths. Medical conditions such as autoimmune disorders that effect the skin, diabetes (uncontrolled) blood clot disorders, blood thinners, keloid scarring, recent chemotherapy or radiation therapy. Medications Accutane 6-12 months, Retinol Retin A Tretinoin 7-14 days, recent chemical peels within 2-4 weeks, laser or IPL treatment 2-4 weeks, recent facial waxing, sugaring, or depilatory creams, recent microneedling or aggressive exfoliation. Recent facial surgery, highly sensative and pregnant

Release of Liability

I voluntarily consent to receive dermaplaning treatment from Chibrowtique. I release and hold harmless Chibrowtique its owner and affiliates from any liability, claims,or damages that may result from this treatment when performed according to professional standards.

Signature and Date

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