Hydrafacial™ Treatment Consent Form
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 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
Yes
No
Open lesion or cold sore
Yes
No
An active infection in the treatment area
Yes
No
Active sunburn
Yes
No
Skin conditions such as eczema, dermatitis, or rashes
Yes
No
An autoimmune disease such as lupus
Yes
No
A viral concern such as HIV or hepatitis
Yes
No
Anticoagulants Therapy
Yes
No
Melanoma or lesions suspected of malignancy
Yes
No
Pregnancy or lactation
Yes
No
Neurological disorders such as epilepsy (LED Lights)
Yes
No
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)
Yes
No
Crohn's Disease (Lymphatic drainage)
Yes
No
Hyperthyroidism (Lymphatic drainage)
Yes
No
Deep Venous Thrombosis (Lymphatic drainage)
Yes
No
Lymphedema (Lymphatic drainage)
Yes
No
*Saying yes does not preclude you from receiving treatments.
Hydrafacial™ Treatment Consent Form
Have you recently?*
Used Accutane, topical medications or antibiotics
Yes
No
Had aesthetic fillers, injectables or laser treatments
Yes
No
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.
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Signature:
Date:
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Day
Year
Date
CS512501/23
Hydrafacial
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