HYDRAFACIAL TREATMENT CONSENT FORM

HYDRAFACIAL TREATMENT CONSENT FORM
Name
Birthday
Address
City
State/Province
Zip/Postal code
Phone #
Format: (000) 000-0000.
Emergency Contact
#
Email
example@example.com
HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from HydraFacial will vary from person to person.
What to expect: Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity. You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. Client experiences may vary. Some clients may experience a delayed onset of these symptoms. You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results. The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40
Please check all/any of the following health conditions you have experienced and/or that you are currently experiencing:
Active Acne
Active Infection
Open Lesion/Cold Sore
Active Sunburn
Eczema, Dermatitis or Rashes
Autoimmune Disease
HIV
Hepatitis
Hepatitis
Melanoma
Lesions suspected of Malignancy
Pregnant or Lactating
Epilepsy
Neurological Disorder
Lupus
Keloids
Rosacea or Telangiectasia
Do you have any Allergies?
No
If Yes, please list ALL allergies:
Are you currently taking any medications including over the counter, prescribed, topical, supplements and vitamins?
NoIf Yes, please list ALL medications you are currently taking:
Yes, please list ALL medications you are currently taking
Have you recently used Accutane, Topical Medications or Antibiotics?
No
If Yes, please list
Have you recently had Aesthetic Fillers, Injectables or Laser Treatments?
Yes
Yes
If Yes, please specify
Should be Empty: