HydraFacial Informed Consent
HydraFacial is an FDA approved device that is used to treat damage and skin textural problems by exfoliating and hydrating the skin. Best results are typically seen after continued monthly sessions, but I understand that clinical results may vary depending on individual factors including but not limited to medical history, sun exposure habits, skin type, patient compliance with pre/post care instructions and individual response to treatment.
Contraindications For This Treatment Include:
Pregnancy
Bacterial or viral infection
Uncontrolled diabetes or high blood pressure
Impaired immune system and poor healing
History of cancer within past 5 years
Accutane within the past 12 months
Scleroderma, Vitiligo, Melanoma, Irregular Pigmentation, Psoriasis
Botox or fillers injected within the last 2 weeks
CO2 laser treatment or similar type treatment in the past 6 months
I am aware of the following risks which include but are not limited to:
Mild to moderate discomfort during the treatment
Redness and/or swelling of the skin lasting up to several days.
Acne flare up
Itching or Irritation
Skin flaking/peeling
I acknowledge that due to my unique skin and/or body composition, there are no guarantees, warranties, or assurances that I will be satisfied with my results.
I understand that this treatment may involve risks of complication from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition or habits that may have a bearing on this procedure including but not limited to medical history, tanning habits, medications, supplements skin care regimen, diet 8 exercise regime, water intake etc.
I consent and authorize my practitioner, who has been trained in HydraFacial, to perform the treatment on me. I agree to pay for this treatment. I understand that I have the right to refuse or stop treatment at any time, but that no refunds will be provided once payment is made.
I certify that have read this entire informed consent that I understand and agree to the information provided in this form as well as the information provided In the Pre / Post Care form. My practitioner has explained the nature of my condition: the nature of the procedure, alternative treatments, and the benefits to be reasonably expected compared with alternative approaches. I have been given the opportunity to ask questions. This document is a written confirmation of these discussions.
I agree that this consent supersedes any previous verb al or writ ten disclosures. This consent is valid for all of my HydraFacial treatments in the future as well.