Aesthetically Yours By Mel

dermaplaning

Consent

Informed Consent for Dermaplaning

I understand that Aesthetically Yours By Melanie will perform a Dermaplaning treatment on my face and neck. Dermaplaning is a medical grade exfoliation to eliminate dead skin cells and vellus hair ( peach fuzz) from the surface of the skin. Dermaplaning is performed using a 10-gauge scalpel at a 45 degree angle to prevent nicking. Dermaplaning is suitable for all skin types unless if contraindications are present. You should not feel any discomfort. You agree to inform Aesthetically Yours by Melanie should you feel any discomfort. You agree that it is possible to cut or nick the treatment area. *

Yes
No

I understand the nature of this service and the potential of risk involved have been explained to me, and accept this treatment as suitable. Contraindications include but agree not limited to other forms of microdermabrasion, cold sores broken capillaries/ couperose, numerous raised lesions, open lesions, allergy to nickel ,sunburn, psoriasis, acne flare ups, rosacea and inflammatory skin conditions such as eczema. *

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No

I acknowledge and confirm that I have not had any waxing or sugaring services in the last 7 days and will avoid them 7 days post treatment. *

Yes
No

I acknowledge and confirm that I have refrained from sun exposure 10 days prior to my Dermaplaning treatment and will avoid direct sun exposure for 72 hours post treatment. *

Yes
No

I acknowledge and confirm that I have not received any Botox or dermal filler in the last 14 days. *

Yes
No

I acknowledge and confirm that I have discontinued usage of Tretinoin, Retinol, Retin-A, Differin, Tazorac, Avage, Epiduo, Ziana 3 days prior to the treatment and have consulted my medical physician prior to stopping my medication. *

Yes
No

I acknowledge and confirm that I have discontinued isotretinoin ( Accutane) 6-12 months prior to the Dermaplaning procedure and have consulted with my medical physician. *

Yes
No

I understand that I must wear SPF 30 + with broad spectrum coverage to protect my skin during sun exposure but agree to avoid sun exposure for 72 hours post treatment. *

Yes
No

I understand I must avoid excessive sweating and strenuous activities for at least 24 hours. *

Yes
No

I acknowledge and accept that I may experience some of the following side effects: redness, tenderness, swelling, irritation, dryness, tingling, tightening, peeling and skin colour changes. *

Yes
No

I certify that I am 18 years of age or older. *

Yes
No

Name (Electronic signature) *

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