CIRCADIA

Name: _____________________________________________________________________

Address: _____________________________________________________________________________________________________________________

Phone Number: __________________________________________________________

Email : ______________________________________________________________________

Date: ____/____/_______

I, ______________________________________, give permission to my skin care professional to perform this treatment.

DERMAPLANING

I agree to complete a Confidential Skin Health Questionnaire. I agree to complete and be truthful about my physical conditions, pregnancy,

medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor

exposure, tanning beds, excessive alcohol consumption and/or recreational use of controlled substances, may affect the outcome of the

treatment.

I have disclosed to my skin care professional/student esthetician any surgical procedures, laser treatments or facial procedures that I have

had or intend on having in the future.

I have not received Botox or fillers within 1 week of this appointment.

I have not used any form of Vitamin A within the past 5 days and will not use Vitamin A for 5 days after the service.

I have not had any recent chemotherapy or radiation treatments in the past year.

I have not recently waxed or used a depilatory (such as Nair) on the area being treated today. I do not have a history of keloid scarring,

diabetes, any autoimmune disease, active herpes blisters or cold sores.

I have not had any other peel treatment of any kind within 14 days of treatment. I understand I cannot have another treatment within 14 days

of this treatment, whether the treatment is performed at this location or any other location.

I agree to refrain from excessive sun exposure or the use of a tanning bed while I am undergoing treatment and during the 14 days following

the end of the treatment.

understand that sun exposure is prohibited while I am undergoing treatment and that the use of Circadia Light Day Broad Spectrum Sunscreen

SPF 37 is mandatory.

I understand the purpose of this peeling procedure is to exfoliate the outer surface of my skin. Some of the benefits include lessening of

pigmentation, reduction in appearance of fine lines and wrinkles, and control of certain conditions such as acne or occasional breakout.

I understand that the following conditions preclude me from having this treatment currently and verify that none of these conditions apply to

me at this time.

_______ Broken skin on areas to be treated

_______ Sunburn or windburn skin

_______ Visible inflammatory or inflammatory lesions

_______ Herpes virus (cold sores) on mouth

_______ Laser Hair Removal within 6 weeks

_______ Use of glycolic acid products

_______ Use of Retin-A®, Renova®, retinoids (Vitamin A) in the last 4 weeks

_______ Allergic to citric fruits (oranges, limes, grapefruit, lemons)

_______ Allergic to cocoa, chocolate, and/or raspberry

_______ Allergic to pineapple and/or papaya

_______ Allergic to aspirin or have any sensitivity to salicylic acid (Alpha-Beta Peel)

My expectations are realistic, and I understand that the results are not guaranteed and that for maximum results, more than one application

may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, or pigmentation levels.

C I R C A D I A

D E R M A P L A N I N G C O N S E N T F O R M

I understand that although complications are very rare, sometimes they may occur, and that prompt treatment is necessary. In the event of

any complication, I will immediately contact the facility where treatment was performed.

I understand the possibility of peeling, flaking, hyperpigmentation and excessive dryness. I agree to use the products specifically

recommended by my skin care professional/student esthetician.

I understand that every precaution will be taken to minimize or eliminate negative reactions such as blisters, redness, or irritation.

I understand that I will have home care products recommended to work in tandem with the in-clinic treatment. I am willing to follow

recommendations by my skin care professional/esthetic student for home care.

I consent to the taking of photographs to monitor treatment effect and results if desired by my skin care professional/esthetic student.

INFORMED CONSENT

In the event of any questions or concerns, I will consult my skin care professional/esthetic student immediately. I understand the potential

risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks,

complications, and limitations. I will hold the skin care professional/esthetic student and staff harmless from any liability that may result from

this treatment.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and

fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.

Client Signature ________________________________________ Date __________________________

Skincare Professional ____________________________________ Date __________________________

C I R C A D I A

D E R M A P L A N I N G C O N S E N T F O R M