Evoke Healing Space - 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.

Do you have any of the following?*

*Saying yes does not preclude you from receiving treatments.

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 of 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

Have you recently?

Used Accutane, topical medications or antibiotics

YesNo

Had aesthetic fillers, injectables or laser treatments

YesNo

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 Galleria Spa Salon Boutique.

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.

Print name*

Signature*

Date*

Date

HYDRAFACIAL TREATMENT CONSENT FORM