HYDRA FACIAL CONSENT FORM

HydraFacial

The only hydra dermabrasion 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 sunscreen.

Name*

First NameLast Name

Phone Number

Please enter a valid phone number.

Email*

example@example.com

Do you have any of the following?

Active acne or infection?

YesNo

Open lesion or cold sore?

YesNo

An active infection in the treatment area?

YesNo

Active sunburn?

YesNo

Skin conditions such as eczema, dermatitis, or rashes?

YesNo

An autoimmune disease such as lupus?

YesNo

A viral concern such as HIV or hepatitis?

YesNo

Anticoagulants Therapy?

YesNo

Melanoma or lesions suspected of malignancy?

YesNo

Pregnancy or lactation?

YesNo

Neurological disorders such as epilepsy (LED Lights)?

YesNo

Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)?

YesNo

Crohn’s Disease (Lymphatic drainage)?

YesNo

Hyperthyroidism (Lymphatic drainage)?

YesNo

Deep Venous Thrombosis (Lymphatic drainage)?

YesNo

Lymphedema (Lymphatic drainage)?

YesNo

*Saying yes does not preclude you from receiving treatments.

Have you recently?

Had aesthetic fillers, injectables or laser treatments?

YesNo

Used Accutane, topical medications or antibiotics?

YesNo

I am 18 years old or older.

Yes, I am 18 years or olderNo, I am not 18 years old. I have parental and/or guardians consent with a signature below

I am not 18 years old. I have parental and/or guardians consent with a signature. By signing below you understand all possible risks that are involved with this service.

Clear

Print Parental/Guardians name:

first and last name

I acknowledge the following:

I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.
Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.

The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at.By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. This consent form Is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.*

Clear

REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for yourself or for another individual are absolutely non-refundable.This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.*

Clear

Today's Date*

Date

Please provide an email for follow up care.*

example@example.com