Hydrafacial Treatment Consent Form

  • Hydrafacial Treatment Consent Form

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Hydrafacial is the only hydradermabrasion treatment 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 susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.

     

    Do you have any of the following?*

  • Active acne or infection*
  • Open lesion or cold sore*
  • An active infection in the treatment area*
  • Active sunburn*
  • Skin conditions such as eczema, dermatitis, or rashes*
  • An autoimmune disease such as Lupus*
  • A viral concern such as HIV or hepatitis*
  • Anticoagulants Therapy*
  • Melanoma or lesions suspected of malignancy*
  • Pregnancy or lactation*
  • Neurological 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)*

  •  

    Have you recently?*

  • Used Accutane, topical medications or antibiotics*
  • Had aesthetic fillers, injectables or laser treatments*

  • *Saying yes does not preclude you from receiving treatments.

  •  

    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 GT Lash And Brows.

    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.

  • Date*
     - -

  • PARENT/GUARDIAN CONSENT

    Please provide your name, signature, and phone number below.
  • Format: (000) 000-0000.
  • Date
     - -
  • Should be Empty: