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HOME
Forms
Brow Lamination Consent Form
Dermaplaning Consent Form
Eyelash Extensions Consent Form
Facial Consent Form
Lash Lift and Lash Tint Consent Form
Tattoo Forms
Waxing Consent Form
402 669 7094
By Appointment Only
4935 S 136th St, Omaha, NE, 68137
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Dermaplaning Consent Form
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Date
*
Email
*
The nature and purpose of this treatment has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction.
I agree to allow pictures to be taken and shared of me.
I understand there are no refunds on services rendered.
I understand that if I choose to reschedule or cancel my appointment I must give a 48hr notice or I will be charged the full price of the service not including any discounts or specials.
I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness of the skin, irritation and dryness.
If a chemical peel or other treatment is part of this treatment I understand that the sensation and penetration of the peel will be enhanced. Which may cause skin irritation, mild discomfort, and tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores?
I certify that I have read this entire consent and that I understand and agree to the information provided in this form. I certify that I am competent adult of at least 18 years of age, or that, if I am a minor under the age of 18, I understand that the consent of my parent/guardian having legal custody will also be required before treatment. This agreement will remain in effect for this procedure and all future procedures conducted by Adore. I have read and fully understand all information in this agreement.
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Do you have the tendency to keloid scar on the face?
Yes
No
Do you currently have an active bacterial, fungal, or viral skin infection on the face, including herpes simplex (cold sore)?
*
Yes*
No
*if yes, the procedure will be rescheduled.
Have you used Accutane in the last six months?
*
Yes
No
Have you had Botox and/or Juvederm or any other filler in the last three weeks?
*
Yes
No
Have you had any waxing of your brows, upper lip or face in the last 72 hours?
*
Yes
No
What products do you use?
Cleanser: Toner: Eye Cream: Serum: Sunscreen:
What is your major reason for being here today?
What skin type and/or problem do you feel you have?
What skin type and/or Have you ever had a facial treatment before? If yes, where and when? Was it a beneficial experience? problem do you feel you have?
Have you ever had a reaction to a food, cosmetic, or skin care product? If yes, please give details:
Where do you purchase most of your face and body care products?
How much time do you spend on your daily skin care/make-up routine?
How you feel about your skin conditions? What would you like to improve?
Do you tend to tan or burn?
Do you smoke or drink? How often?
Do you exercise and how often?
How much sleep do you get per night?
Are you interested in long or short term spa treatment?
Are you pleased with your current products:
I understand the following statements:
It is imperative that you use a sunscreen with an SPF of at least 20 and avoid direct sunlight for at least 1 week.
Patients with hypersensitivity to the sun should take extra precautions to guard against exposure immediately following the procedure as they may be more sensitive following the peel.
Your skin may be more red than usual for 2 to 3 days. Please avoid strenuous exercise during this time.
Approximately 48 hours after the treatment your skin will start to peel. This peeling will generally last 2 to 5 days. DO NOT PICK OR PULL THE SKIN.
When washing your face, do not scrub. Use a cleanser that does not contain soap.
Apply a light moisturizer to relieve dryness and tightness.
Do not have any other facial treatment for at least 1 week after your peel.
it is common and expected that the skin will be red and possibly itchy and/or irritated. It is also possible that other adverse experiences (side effects) may occur.
Although rare, the following adverse experiences have been reported by patients after having a Peel; skin breakout or acne, rash, dark spots, swelling and burning.
LACK OF EFFECT: although most people experience peeling of their facial skin, not every client notices that their skin peels after a Peel procedure. Lack of peeling is NOT an indication that the peel was unsuccessful. If you do not notice actual peeling, please know that you are still receiving all the benefits of the Vitalize Peel, such as: stimulation of collagen production, improvement of skin tone and texture, and diminishment of fine lines and pigmentation.
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I agree and adhere to all safety precautions and regulations during the skin treatment. I have received and understand the post care recommendations as follows: no sun exposure for 48 hours, moisturize as needed and use gentle cleanser only. Use of sunscreen is highly recommended post-treatment for at least next 7 days. (SPF 30)
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