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Consent Form

Sei Tu Bella Aesthetics logo

Dermaplaning Consent Form

Please initial each line next to each statement prior to treatment
_______ I understand that Dermaplaning is the process of removing superficial layers of dead skin cells and vellus hair on the skin’s surface by the use of a sterile blade.

_______ I understand that there may be unforeseen risks with Dermaplaning such as nicking, scraping or abrading the skin with the blade.

_______ I understand that possible side effects of the treatment area can include mild redness of the skin, irritation, and dryness.

_______ I understand that if a chemical peel is part of this treatment, that the sensation and penetration of the peel will be enhanced. This may cause minor skin irritation, mild discomfort, tenderness, lightening or darkening of the skin, peeling, and activation of cold sores.

_______ I understand the results of this treatment may vary due to conditions such as age, condition of the skin, sun damage, climate, etc.

_______ I understand that in order to see significant results these treatments need to be done in a series and in combination with using active ingredient skin care products.

_______ I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment and the use of daily sun block protection is mandatory.

_______ I understand that any facial injections should be avoided 10 days before this treatment.

_______ I am not using Retin A®, or other retinol derivatives, products containing Alpha Hydroxy Acids (AHA) or Beta Hydroxy Acids (BHA) and have been off these products at least 3 days prior to treatment.

_______ I will call my practitioner if I have any questions or concerns about my treatment.

_______ I have been advised not to exercise after my treatment.

I agree to have this treatment performed on me. I further agree to follow all post-care instructions. Prior to receiving any treatment, I have been candid in revealing any condition that may have a bearing on this procedure. I am over 18 years of age.

I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.

I consent and authorize Sei Tu Bella Aesthetics, LLC, and its affiliates to perform the procedure listed on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent is valid for all of my treatments in the future as well.

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