HydroFacial Consultation and Waiver Form

Client Consultation Form
Personal/Medical History Form

To ensure you receive the most appropriate HydroFacial treatment, please complete the following questionnaire. All information provided will remain strictly confidential.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact Name*
Full Name
Emegency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us*

FacebookInstagramGoogleFamily or Friend

HYDROFACIAL CONTRAINDICATIONS
A contraindication is a condition or factor that may make a client unsuitable for HydroFacial treatment due to health risks or the possibility of adverse outcomes. Please consult with your technician before the procedure if any of the following apply to you:

Not Recommended for Clients Who Are or Have:
- Pregnant or breastfeeding
- Open wounds, cuts, abrasions, burns, or active skin conditions
- Recent facial surgery
- Currently using Retin-A, Accutane, or other strong exfoliants
- Any active skin infections (e.g., impetigo) or conditions such as conjunctivitis
- Have had Botox, fillers, chemical peels, or microneedling within 2 weeks
- Recent laser treatments, or dermabrasion
- Have sunburn, open wounds, or very sensitive skin
- Are allergic to ingredients used in HydroFacial solutions (e.g., salicylic acid, glycolic acid, hyaluronic acid)
- Bell’s Palsy or facial nerve conditions
- Any condition causing involuntary facial movements (e.g., twitching, tremors)
- Have active cold sores, infections, or contagious skin conditions
Contraindications Requiring Extra Caution
- Autoimmune diseases affecting skin
- Skin medications or treatments that thin or irritate the skin
- Post-chemotherapy recovery (must be medically cleared)
- Rosacea or similar chronic skin conditions near the brows
Please disclose any medical conditions, allergies, or recent procedures to your technician prior to your appointment. Your safety and the effectiveness of the treatment depend on accurate and honest communication.
Acknowledgement*

I acknowledge that I have reviewed the list of health conditions and contraindications that may affect the safety and effectiveness of the HydroFacial procedure. I have disclosed any relevant medical issues to the technician and understand that failure to do so may increase the risk of complications. I accept that the technician may refuse or postpone treatment if necessary for my safety. By checking this box, I confirm I have read, understood, and agree to these terms.

Client Consultation Form

Medical History

HYDROFACIAL CONTRAINDICATIONS

AFTERCARE

ACKNOWLEDGMENT