The Skin Edit by Melissa Jordan

    The Skin Edit · Abbotsford, BC

    Dermaplaning
    Intake & Consent Form

    Please complete all sections carefully. Your answers help ensure dermaplaning is safe and appropriate for your skin.

    1. Client Information

    2. Skin Analysis & Lifestyle Questionnaire

    What is your primary skin type?

    What are your main skin concerns? (Check all that apply)

    Have you ever had a professional dermaplaning treatment before?

    When exposed to the sun, your skin typically:

    Are you a smoker?

    Do you wear contact lenses?

    For female clients: Are you currently pregnant, nursing, or taking birth control?

    3. Medical History & Contraindications

    Please answer accurately to ensure your safety during this clinical exfoliation process.

    In the past 48 hours, have you had a chemical peel, microdermabrasion, waxing, or significant sun/tanning bed exposure?

    In the past 7 days, have you used Retin-A, Retinoids, Glycolic/Alpha Hydroxy Acids, Salicylic Acid, or Hydroquinone?

    In the past 7 days, have you received Botox, dermal fillers, or cosmetic injectables?

    In the past 6–12 months, have you used Accutane or undergone chemotherapy/radiation treatments?

    Do you currently have a sunburn, open wounds, active cystic acne, or raised lesions on your face?

    Are you prone to cold sores or fever blisters?

    Do you have a history of keloid scarring, diabetes, bleeding disorders, or autoimmune conditions?

    Are you allergic to aspirin, salicylic acid, citrus, or latex?

    4. Informed Consent & Liability Waiver

    Procedure Description: Dermaplaning is a mechanical exfoliation process using a sterile, surgical blade to gently scrape away dead skin cells and fine vellus hair ("peach fuzz").

    Expected Results: Smoother skin texture, brighter complexion, and improved absorption of skincare products. Results vary, and alternative or multiple treatments may be necessary to achieve your aesthetic goals.

    Potential Risks: While rare, risks include minor nicks or cuts, temporary skin scraping, mild redness, irritation, or an outbreak of cold sores if you carry the virus.

    Client Acknowledgement: I understand that vellus hair will not grow back thicker or darker. I certify that I have read this form completely, answered all medical questions truthfully, and accept the risks associated with this cosmetic treatment. I release this facility and my esthetician from liability regarding complications resulting from undisclosed medical history.

    5. Post-Treatment Aftercare Commitment

    To be filled out and provided to the client post-service.

    Signatures

    Please complete all required fields, screening questions, acknowledgements, and signature before submitting.