Dermaplane


 

 Lavender-Falls-Stone-Oak-Spa-San-Antonio

Lavender Falls Face & Body Spa LLC

Client Informed Consent Form

Dermaplane

 

PLEASE READ CAREFULLY & COMPLETELY

 

 

19239 Stone Oak Pkwy #201

San Antonio, Texas 78258

Phone: 210-446-0903

www.sanantonio.lavenderskinspa.com

Online Booking Available

Treatment Consists of:

Dermaplaning is a gentle medical skin treatment that is performed by using a surgical blade that gently scrapes the outermost layers of the epidermis, therefore, ridding it of dead skin cells, impurities and debris. Dermaplaning also temporarily removes the fine vellus hair of the face (hair does not grow back thicker), leaving a very smooth surface. This treatment is an excellent way to exfoliate the skin and regenerate new skin cells, leaving the complexion smooth, soft and vibrant.

Clients Acknowledgements:

Contraindications include but are not limited to the following conditions:

Allergy to nickel, recent use of Accutane, eczema, dermatitis, malignant skin tumors, open lesions, lupus, active herpes infection, sunburn, keratosis and blood thinners.

Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

      Accutane with the last year

      Allergy to Nickel

      Sunburn or Sun Exposure (tanning beds) - 1 week prior to treatment.

      Recent Laser Treatments or Chemical Peels

      Electrolysis, Waxing , Depilatory Creams , Laser Hair Removal – 1 week prior to treatment

      No prescriptive topicals, abrasive scrubs or strong exfoliants – 1 week prior to and post treatment.

(Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol, glycolic acid, salicylic acid)

      

Cosmetic Injections:

      Botox/Dysport/Xeomin within the last week.

      Dermal Fillers within the last two weeks.

*Notify your aesthetician of any medical conditions & medications (Current & within the last 90 days).

Post Treatment Acknowledgement

Avoid direct sun exposure and excessive heat.

IMPORTANT: Keep your skin hydrated. Hydration is key to proper healing.

      DO NOT tan or use a tanning booth for at least 14 days post treatment

      Sun protection of at least broad spectrum SPF 30 is recommended.

      DO NOT cleanse your skin the evening of your peel or treatment.

      DO NOT pick or pull any flaking skin.

      DO NOT have electrolysis, waxing, threading or any other form of hair removal for 7 days post treatment.

      DO NOT use facial scrubs or mechanical forms of exfoliation for 14 days post treatment.

      DO NOT use retinoic acid, AHA or BHA 14 days post treatment.

      DO NOT have laser hair removal, photo facials, chemical peels or microdermabrasion for 14 days post treatment.

      DO NOT apply ice or ice water on the treated area.

      DO NOT use hot tubs, steam rooms, saunas, and/or excessively hot showers for 2 days post treatment.

      DO NOT go swimming for 2 days post treatment

      DO NOT participate in aerobic exercise for 2 days post treatment.

Side Effects:

Possible side effects include but are not limited to:

• Common side effects such as slight redness, tightness, peeling, flaking or temporary dryness.

• May cause minor superficial nicks or abrasions which may not appear until a day or two following your treatment.

Acknowledgements:

      I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

      The Dermaplane treatment has been fully explained and any questions or concerns that I have, have been addressed.

      I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

      I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

      Photographs May be taken for comparison for future treatments for my chart.

 

I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.

 

I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.

 

All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.

  

 

 

 

 

Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face & Body Spa LLC for your aesthetic needs

Feel free to contact us at 210-446-0903 if you have any questions

 

           

 

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Signature Certificate
Document name: Dermaplane
lock iconUnique Document ID: e97be733e0f9fb21c164787d3e1571d6cb7720e7
Timestamp Audit
April 8, 2017 7:55 pm CSTDermaplane Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP 162.198.97.65