Treatment Readiness

Consent

DERMAPLANE CONSENT FORM

Glo With Ally

DERMAPLANE CONSENT FORM

First Name

Last Name

I, , agree to having to undergo this treatment/procedure after having the treatment details and nature of the treatment along with risks and hazards involved by qualified beauty therapist/esthetician Ally Gould.

I understand that dermaplaning is a method of exfoliating the top layer of skin using a scalpel or other similar tool. I acknowledge that this procedure is not permanent and may require repeated treatments to maintain desired results.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I understand that there may be risks and side effects associated with dermaplaning, including but not limited to, skin irritation, redness, itching, swelling, and infection. I acknowledge that I have discussed these risks with my provider and have had any questions or concerns addressed to my satisfaction.

I have also, to the best of my knowledge given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and understand the post-treatment aftercare instructions. I understand how important it is to follow all aftercare instructions given to me.

Is this your first time recieving this specific service at Glo With Ally

Yes

Have there been any changes to your health history, medications, skincare routine, allergies, pregnancy status, or any other information that may affect your treatment since you last completed your consultation form.

Yes

If you answered 'Yes,' please complete a new consultation form for this service to ensure your information is current and accurate.

Please check the circle to confirm your understanding

I have read and understand this agreement and all information detailed above. I understand the procedure and accept the risks. I do not hold the esthetician, Ally Gould, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by treatment performed today.

Accuracy Declaration

I certify that the information I have provided is complete and accurate to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the safety and effectiveness of my treatment. I agree to notify Glo with Ally of any changes to my health, medications, skincare products, or other relevant information before receiving future services.

Type Full Name to Sign

Date of Signature

I agree to the terms outlined above.

Yes

By checking the validation box and typing your name, you acknowledge that you have completely read and fully understand the above agreement, and that your typed name stands as your legally binding digital signature under the US ESIGN Act.