Dermaplane Consent and Questionnaire
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Email *
Name *
First & Last
Date of Birth *
MM
/
DD
/
YYYY
Cell phone number *
Do you have any current or chronic medical illness? *
If YES, please explain in the 'other' section.
Do you have a history of any of the following? *
Check all that apply
Required
Do you have any current or chronic skin conditions? *
If YES, please explain in the 'other' section.
Do you have a history of any of the following? *
Required
Are you currently under doctor's care? *
If YES, please explain in the 'other' section.
Do you take/use ANY medications (prescription & non-prescription supplements), vitamin, herbal or natural supplements on a regular basis? *
If YES, please explain in the 'other' section.
Are there any topical products (both medical & non-medical), that you use on your skin on a regular basis? *
If YES, please explain in the 'other' section.
Required
Are you currently taking ANY systemic/oral steroids (e.g., prednisone, dexamethasone)? *
If YES, please explain in the 'other' section.
Do you have ANY allergies to medication, foods, or other substances? *
If YES, please explain in the 'other' section.
Are you, or could you be pregnant? *
Are menstrual  cycles irregular, or have you ever been diagnosed with Polycystic Ovarian Disorder (PCOS)? *
Do you have a history of Herpes I or II in the area to be treated? *
Do you have a history of keloid scarring or hypertrophic scar formation? *
Do you have a history of light induced seizures? *
Do you have any open sores or lesions? *
Required
Do you have any history of radiation therapy in the area to be treated? *
In the last 6 months, have you used any of the following? *
Required
In the last 3 months, have you used any of the following products? *
Required
Do you have or have you ever had any permanent makeup, tattoos, implants, or fillers (including but not limited to collagen, autologous fat, Restylane, etc.) *
If YES, please explain in the 'other' section with dates.
Required
Have you taken Accutane (or products containing isotretinoin) in the last 12 months? *
Required
Have you taken/used Tretinoin (like Retin-A or Renova) in the last 6 months? *
Have you had any unprotected sun exposure or used tanning beds in the last 4-6 weeks? *
Do you have a pacemaker? *
In our treatment session, it may be necessary to recommend alterations or additions to your home care regimen: would that be okay with you? *
Your esthetician will recommend the appropriate schedule for future facial treatments in order to achieve your skin improvement goals.
I consent to the taking of photographs to be posted on social media and/or the website.  *
By typing my name below I declare that I do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the esthetician will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my esthetician immediately. I release and hold harmless the esthetician, Maggie Guy at Naked Aesthetics, harmless from any liability for adverse reactions that may result from this treatment. By typing my name below, I have read and understand all of the foregoing information. *
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