Welcome. Dermaplane + Nano-PDRN Intake Name * First Name Last Name Date Of Birth * Sex Female Male NB Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Would you like to learn more about skincare products and routines? Sure! No, thank you. Are you okay with Paige taking photos that she could share for marketing purposes? OMG, of course! No, thank you. Emergency contact * Name and Phone number Referred by How did you hear about us? What products are you currently using? * MEDICAL HISTORY Do you have or have you had any of the following conditions? If yes, please select them: Acne Arthritis Asthma Blood disorder Cancer Diabetes Eczema Epilepsy Fever blisters Heart condition Herpes Hepatitis High blood pressure HIV/AIDS Hyper pigmentation Hypo pigmentation Hysterectomy Immune disorders Insomnia Keloid scarring Low blood pressure Lupus Metal bone pins/plates Phlebitis, blood clots Seizure disorder Skin disease/lesions Seborrhea Thyroid condition Varicose veins Warts Any other condition: Any known allergies? * Known allergies (medication, foods, shellfish, latex, skincare ingredients, etc.): Are you allergic to salmon DNA / PDRN? * List any medications you take regularly, including vitamins, herbal supplements, aspirin: Any recent surgery, including plastic surgery? If yes, explain Are you pregnant or trying to become pregnant? Yes No Your exposure to the sun? Never Light Moderate Excessive When you go out into the sun, do you (check one) Aways burn (I) Usually burn (II) Sometimes burn (III) Rarely burn (IV) Very rarely burn (V) Never burn (VI) Do you smoke? No Yes Skin Concerns * Acne Blackheads Broken Capillaries Comedones Cherry Angioma Discoloration Dryness/Dull Skin Eczema Fine lines/Wrinkles Hyper pigmentation Hypo pigmentation Milia Oily Skin Psoriasis Redness Rosacea Sensitivity Sun Damage Have you been treated for (please check) Acne Depression Skin Disease High Blood Pressure Cold Sores Diabetes Cancer Have you ever used acne medication? * If yes, when? And which Drug? Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products? * If yes, please describe Have you received Botox, Restylane, or Collagen injections in the last 6 months? * If yes, please describe Have you had Dermaplaning before? Yes or No? If so what date? Have you had Nano Needling before? Yes or No? If so what date? Potential Risks / Contraindications * I understand this treatment may involve: Dermaplaning (exfoliation + hair Nano‑needling (non‑invasive, PDRN (salmon DNA biologic) I confirm I’m not allergic to PDRN (salmon DNA), have disclosed all conditions/medications, and understand skin reactions (redness, peeling, swelling, pigmentation, bruising, infection—rare). Aftercare & Acknowledgement * I agree to follow pre‑ and post‑treatment instructions, including sunscreen, hydration, avoiding sun/exercise, not picking skin. I understand results vary and multiple sessions may be needed; this is an elective cosmetic procedure with no guarantees. I release Paige Ashley Aesthetics and staff from liability for known/unknown effects if proper care is followed. 🩷 Thank you! 🩷 Follow forSpeical Offers!
