Hydropeel I, II, Aqua Diamond Peeling Consent

Hydropeel or Aqua Diamond Peeling Consent

Treatment may include: enzymes, acid peels, extractions, microcurrent, electrical muscle stimulation (ems), galvanic, high frequency, ultrasonic, LED light therapy, oxygen therapy, and other treatment modalities as necessary.
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Please select the treatment you are receiving:

Hydropeel IHydropeel IIAqua Diamond Peeling
Medical History
Have you had any of these health conditions in the past or present(Please check all that apply)*

AnemiaAny Active InfectionsCancerEpilepsy SeizuresHerpesHepatitisHIV/AIDSKeloid ScarringRosaceaSkin CancerSkin Disease/Skin LesionsThyroid ProblemsNone
Other illnesses:
Are you Pregnant or Nursing?*

PregnantNursingNo
Are you allergic to Aspirin?*

YesNo
Are you or have you been on Accutane within the past 6 months?*

YesNo
Have you used Retin-A, Renova, AHA or Retinol derivative products within the past 5 days?*

YesNo
Please list any Oral or Topical Medications you are currently taking:
Please read ALL of the following statements carefully and indicate your understanding and acceptance
Purpose & Background*

The HydroPeel I & II or Aqua Diamond Peeling treatments removes dead skin cells and extracts impurities while simultaneously providing the new skin with cleansing, extractions, hydrating and moisturizing serums. HydroPeel I & II or Aqua Diamond Peeling treatments are safe for all skin types as it is completely noninvasive and non- irritating.
Procedure*

During the treatment, the skin is cleansed and then the HydroPeel I & II or Aqua Diamond Peeling treatment is administered. Each treatment is customized to meet the unique skin conditions of each patient. The treatment itself is often described as feeling like "a cool paintbrush with a vacuum” moving over the skin. Following the Hydropeel I & II or Aqua Diamond Peeling treatment, the skin is moisturized and protected with sunscreen. For best results, it is necessary to complete a series of six treatments, however, improvement may be seen after just one treatment.
Benefits:*

Many people report seeing visible skin refinement and an even, radiant skin tone after just one HydroPeel I & II or Aqua Diamond Peeling treatment. The smooth results and hydration may last 5 to 7 days or even longer. A series of 6 treatments are recommended for improving the appearance of fine lines, wrinkles, hyperpigmentation, acne and oily skin. After your first series of treatments, you may want to maintain your results with a HydroPeel I & II or Aqua Diamond Peeling treatment every 2 to 4 weeks.
Discomfort & Risks:*

I understand that while adverse effects are rare, there is a possibility that my skin may be slightly red, itchy and/or irritated after the HydroPeel I & II or Aqua Diamond Peeling treatment. Since there is no downtime from the HydroPeel I & II or Aqua Diamond Peeling treatment, clients may return to their normal activities immediately after the treatment and may apply makeup right away if desired.
Contraindications:*

Pregnancy, Breast-feeding, Allergy to aspirin are a contraindication. If you have any contraindications please inform your Esthetician/Skincare Therapist prior to treatment
Alternatives:*

HydroPeel I & II or Aqua Diamond Peeling treatments are strictly a voluntary cosmetic procedure; no treatment is necessary or required. HydroPeel I & II or Aqua Diamond Peeling treatments will not eliminate sagging or excess skin and is not meant to be a substitute for surgical lifting. Alternative treatments may include but are not limited to microdermabrasion, chemical peels, laser resurfacing, or doing nothing at all.
Clinical Photography:*

I understand that clinical photographs may be taken at each appointment and are considered a confidential and essential component of my medical record. The photographs will not be used for or disclosed for any media purposes without my signed permission on a separate media consent form.
Results Not Guaranteed:*

Although good results are expected, there cannot be any guarantee or warranty, expressed or implied, on the results that may be obtained. I understand that to achieve maximum results, the protocol prescribed by Skin Facial Bar, LLC should be adhered to. The number of treatments and results of treatment vary per patient and may be affected by the following factors, including but not limited to: Fitzpatrick skin type, tanning habits and sun exposure, patient age, degree of skin irregularity, hormonal changes and/or disorders, individual medical history, medications, lifestyle choices such as smoking, and individual response to treatment. I understand and acknowledge that payment for the above procedure is non-refundable and that if more result is desired then I will be responsible for purchasing additional HydroPeel I & II or Aqua Diamond Peeling treatments to achieve the outcome I desire.
Sun Avoidance:*

I understand that sun exposure of any kind, including natural sun and tanning beds must be avoided in the treatment area(s) for a minimum of 2-7 days before treatment and 1 week after each treatment. Recent sun exposure, tan, or sunburned skin could result in an adverse outcome from the treatment. If my appointment is canceled due to noncompliance, I understand that I will be charged the full value of the service.
Complete Medical History:*

I have truthfully and accurately disclosed all personal medical history information including but not limited to: all previous aesthetic procedures; invasive medical procedures; my use of all medications, drugs, herbs, vitamins, or other supplements of any kind; and all known allergic reactions. I understand that failure to do so may negatively affect my treatment outcome. I further understand that elective aesthetic procedures should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that the providers at Skin Facial Bar, LLC are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of each treatment should be construed as such. Because treatments should not be performed under certain medical conditions, I affirm that I have disclosed all my known medical conditions and all medications I am currently taking. I agree to keep Skin Facial Bar, LLC updated as to any changes in my medical profile and understand that there shall be no liability on Skin Facial Bar, LLC's part should I fail to do so.
Topical & Oral Medications:*

I understand that prior to each treatment it is imperative that I report any topical or oral medications (prescription and non-prescription) that I am currently using or have used in the last 90 days. I understand that some medications may produce an increased sensitivity to the HydroPeel I & II or Aqua Diamond Peeling treatment. Should I begin using any new medications during the course of treatments, I will inform my provider. I release Skin Facial Bar, LLC and its employees of any and all responsibilities relating to adverse reactions due to non-disclosure.
Pre & Post Care Compliance:*

I acknowledge that Skin Facial Bar, LLC has explained to me the “Pre and Post Care” instructions for this procedure. I understand it is important to follow these instructions to maximize treatment results and to minimize the chance of an adverse reaction. I accept all responsibilities of adverse reactions due to noncompliance with pre and post treatment care guidelines.
Questions & Concerns:*

I agree if I have any questions, prospective adverse reactions, or concerns regarding my HydroPeel I & II or Aqua Diamond Peeling treatment I will contact Skin Facial Bar, LLC immediately within 48 hour of the treatment 703.827.3777. I understand that if I do not contact Skin Facial Bar, LLC within 48 hours of the time of treatment then Skin Facial Bar, LLC may not be able to accurately determine whether my question or concern is directly related to the procedure. If I choose to consult my own physician or seek any other medical attention it is at my own expense.
Release & Liability:*

I release all Skin Facial Bar, LLC and any of its employees/staff from liability associated with this procedure except for any liability that may be imposed by the laws of the state of Virginia.
Binding Arbitration Agreement:*

In the case of any dispute, I agree to make a good faith effort to resolve the matter directly with Skin Facial Bar, LLC. If the matter cannot be resolved directly with Skin Facial Bar, LLC I agree to forego litigation and submit to binding arbitration in the state of Virginia.
Certification of Consent to Proceed with Treatment:*

I understand that this treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. I understand that if I am not willing to accept all risks associated with this procedure then I should not have the Hydropeel I & II or Aqua Diamond Peeling treatment. I certify that all my questions have been addressed and answered to my satisfaction, that I have read this entire consent, and that I understand and agree to the information herein. I understand that to receive HydroPeel I & II or Aqua Diamond Peeling treatment at Skin Facial Bar, LLC, I must comply with all stipulations outlined in this consent form; if I do not agree then I will not be able to proceed with treatment. I freely and voluntarily accept all risks associated with HydroPeel I & II and/or Aqua Diamond Peeling treatment and elect to proceed with treatment today as well as future and ongoing treatments.
By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.
Date*

MonthDayYear
Date
Signature*

Clear
Skin Facial Bar LLC | 8300 Old Courthouse Rd. Suite #240, Vienna, VA 22182 | 703-827-3777
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Hydropeel or Aqua Diamond Peeling Consent

Medical History

Please read ALL of the following statements carefully and indicate your understanding and acceptance