DERMAPLANING CONSENT FORM INSTRUCTIONS  

This is an informed-consent document that has been prepared to help inform you about  Dermaplaning, its risks, as well as alternative treatment(s). It is important that you read this  information carefully and completely. Please sign the consent as proposed by your provider  and agreed upon by you.  

GENERAL INFORMATION This procedure will utilize a surgical stainless steel blade to improve  the appearance of the epidermis in adults. The goal is the removal of superficial exfoliation and  facial hair.  

ALTERNATIVE TREATMENTS Alternative forms of management include not treating the the  skin by any means. Other treatments would also include skin peels, laser skin resurfacing and  laser treatments.  

Unsatisfactory Result: Although good results are expected, there is no guarantee or warranty  expressed or implied, on the results that may be obtained. The more realistic your expectations  as to results, the better your results will appear to you. Some patients never achieve their  desired goals or results, at no fault of the provider. You may be disappointed with the results of  treatment. It may be necessary to perform additional treatments to improve your results.  Unsatisfactory results may NOT improve with each additional treatment.  

 Important Commitments/Travel Plans: Any procedure holds the risk of complications that may  delay healing and your return to normal life. Please let the provider know of any travel plans,  important commitments already scheduled or planned, or time demands that are important to  you, so that appropriate timing of the procedure can occur. There are no guarantees that you  will be able to resume all activities in the desired time frame.  

Long-Term Results: Subsequent alterations in the appearance of your body may occur as the  result of aging, sun exposure, weight loss, weight gain, pregnancy, menopause or other  circumstances not related to your procedure.  

Female Patient Information: It is important to inform your provider if you use birth control pills,  estrogen replacement, or if you suspect you may be pregnant. Many medications including  antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and  pregnancy.  

Mental Health Disorders and Elective Procedures: It is important that all patients seeking to  undergo elective procedures have realistic expectations that focus on improvement rather than  perfection. Complications or less than satisfactory results are sometimes unavoidable, may  require additional procedures and often are stressful. Please openly discuss with your provider,  prior to treatment, any history that you may have of significant emotional depression or mental 

health disorders. Although many individuals may benefit psychologically from the results of  elective procedures, effects on mental health cannot be accurately predicted.  

PATIENT COMPLIANCE: Follow all provider instructions carefully; this is essential for the  success of your outcome. Personal and vocational activity needs to be restricted. It is important  that you participate in follow-up care, return for aftercare, and promote your recovery.  

DISCLAIMER Informed-consent documents are used to communicate information about the  proposed surgical treatment of a disease or condition along with disclosure of risks and  alternative forms of treatment(s), including a decision not to proceed with treatment. This  document is based on a thorough evaluation of scientific literature and relevant clinical practices  to describe a range of generally acceptable risks and alternative forms of management of a  particular disease or condition. The informed-consent process attempts to define principles of  risk disclosure that should generally meet the needs of most patients in most circumstances.  However, informed-consent documents should not be considered all-inclusive in defining other  methods of care and risks encountered. Your provider may provide you with additional or  different information which is based on all the facts in your particular case and the current state  of medical knowledge. Informed-consent documents are not intended to define or serve as the  standard of medical care. Standards of medical care are determined on the basis of all of the  facts involved in an individual case and are subject to change as scientific knowledge and  technology advance and as practice patterns evolve. 

AUTHORIZATION (S):  

Before and after treatment instructions have been discussed with me.  

The procedure, potential benefits and risks, and alternative treatment options have been  explained to my satisfaction.  

I understand that my treatment is purely elective, that the results may vary with each individual,  and multiple treatments may be necessary.  

I have read and understand all information presented to me before consenting to treatment.  I have had all my questions answered.  

I understand that I am a patient of Medical Aesthetics Associates, PC, a medical practice led by  a Harvard trained Board Certified Plastic Surgeon with over two decades of medical aesthetic  experience, and that my licensed provider is an employee of the practice.  

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 PATIENT SIGNATURE  

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 PROVIDER’S NAME PROVIDER