Treat Yourself Please complete and submit all consent forms before booking your appointment. Dermaplaning Consent and Release Form "*" indicates required fields Step 1 of 2 50% Dermaplaning is a physical/mechanical form of exfoliation using a specialized dermaplaning blade for the removal of built-up dead skin cells and villous hair. Following treatment, skin will be smoother, softer, and better able to absorb the active ingredients in treatment and home care products. I understand this treatment involves the use of the sterile, surgical blade to remove dead skin cells and vellous hair. As with the use of any sharp instrument, there is the possibility of nicks or cuts. I understand there are contraindications to this treatment, including but not limited to, diabetes (not controlled by diet or medication), cancer, active acne, bleeding disorders, the inability for blood to coagulate or the development of keloids following injury. Certain medications including blood thinners, higher dosages of Aspirin, and Accutane are contraindicated for this treatment due to the possibility of delayed clotting from a nick or cut. I certify that I am not taking any of the above medications or experiencing any of the above conditions. While every precaution will be taken to avoid nicks, cuts and scratches, I understand the risks and consent to treatment today.Consent* I give my consent for dermaplaning to be performed by Bella Aesthetics.Photograph Release Consent*Bella Aesthetics Med Spa would like to take before and after photographs depicting the results of your procedure. We would also like your permission to use these photographs for advertising. Advertising may include portfolios, brochures, online or print advertisements, etc. Please check “YES” or “NO” below to indicate whether you consent to our use of your photographs for advertising purposes. YES, feel free to use photographs of me. NO, please do not use photographs of me. What concerns you the most aout the overall appearance of your skin? (check all that apply)* Acne Blackheads Bumps on back of arms Dehydrated Skin Facial Veins Large Pores Oily Skin Rosacea Under Eye Puffiness/Dark Circles Acne Scarring Body Acne Cellulite Dull Complexion Fine Lines/Wrinkles Loss of Lashes/Brows Redness Sagging Skin Age Spots Broken Blood Vessels Cysts/Nodules Excessive Facial Hair Frequent Breakouts Melasma/Brown Spots/Patches Rough/Uneven Skin Tone Sun Damage Other What are your other concerns about your skin?*How would you describe your skin? Oily Dry Combination Sensitive How would you describe your stress level? Little Moderate High Severe Do you feel your stress level may be affecting the health of your skin? Yes No Are you in good health overall? Yes No What are your health concerns?* Medical HistoryAre you currently under the care of a physician? Yes No If you are under the care of a physician, please explain.*Do you have allergies to food or medications? Yes No Please explain your allergies to food and/or medications*Are you currently on any medications either topical or oral? Yes No Please explain your medications.*Ethnic Background(Parents, Grandparents, and Great Grandparents)How do you heal after an acne breakout, cut or scratch? No scar Red Brown (PIH) Do you smoke? Yes No Are you prone to cold sores? Yes No Do you have an allergy to latex? Yes No Do you tan in the sun or in tanning beds/booths? Yes No When was your last cold sore?Please check the skincare products you are currently using: Cleanser Serum Toner Scrub Mask Eye Cream Moisturizer Sunscreen Self Tanner Concealer Makeup Other Anything else we should know?Please upload a picture of your ID to verify that you are over 18 years of age.*Max. file size: 500 MB.Consent*I acknowledge that I am at least 18 years of age and I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Bella Aesthetics Med Spa to perform the dermaplaning procedure on me. I hereby release Bella Aesthetics Med Spa from any liability arising from the risks that are known and/or inherent in the dermaplaning procedure. I agree.SignatureToday's date* MM slash DD slash YYYY Name*Please type your name below. First Last Phone Number*Email Address* Referred ByPhoneThis field is for validation purposes and should be left unchanged.