Hydrafacial Treatment Consent Form

Hydrafacial Treatment Consent Form
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 sunscreen.
Active acne or infectionOpen lesion or cold soreAn active infection in the area to be treatedActive sunburnSkin conditions such as eczema, dermatitis, or rashesAn autoimmune disease such as lupusA viral concern such as HIV or hepatitisAnticoagulants TherapyMelanoma or lesions suspected of malignancyPregnancy or lactationNeurological disorders such as epilepsy (LED Lights)Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)Crohn’s Disease (Lymphatic drainage)Hyperthyroidism (Lymphatic drainage)Deep Venous Thrombosis (Lymphatic drainage)Lymphedema (Lymphatic drainage)N/A
*Having any of the above conditons does not prevent you from receiving treatment.
Used Accutane, topical medications or antibioticsHad aesthetic fillers, injectables or laser treatmentsN/A
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 a minimum of 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 licensed practioners at Rawe Beauti Skin + Body Bar.

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.
Control acne breakoutsFirm skinRevise hyperpigmentationI just want to relax
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Today's Date*

MonthDayYear
Date
Signature*

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By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.
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