HE Hydrafacial

Hydrafacial

Healing Elements Day Spa
CLIENT CONSULTATION AND RELEASE FORM
Please read carefully, complete, sign and date this form prior to your treatment.
Name
Phone
Address
City
State
Zip
Email
example@example.com
What services have you had before

HYDRAFACIALBLUE LED LIGHT THERAPYRED LED LIGHT THERAPYLYMPHATIC/MASSAGE THERAPYWET DIAMOND (Medical Use Only)
SECTION 1: MEDICAL INFORMATION
Do any have any of the following allergies?

ShellfishAspirin SulfurDo you have any of the following allergies?PreservativesOther
Do any of the following conditions relate to you?

Accutane or other similar medicationsAutoimmune disease, HIV, Lupus, Hepatitis, SclerodermaBlood Thinners - Heparin, coumadin, warfarin, daily aspirin, or Vitamin EBreast feeding, pregnancyCancer or post-cancer treatmentsCardiovascular problemsCold sores or fever blisters without pre-medicationCortisone or steriod injectionsCosmetic injections, fillers,or implants (ie Botox, collagen)Eczema, psoriasisEnlarged or painful glandsEpilepsyFacial waxing services w/in 7-14 daysHeart AilmentsHypertension/high blood pressureInflammatory conditionsIrregular, pigmented moles, warts or growths, unidentified facial growth or markKeloids, pigmented scars, icepick scars, new scar tissueLaser procedures, chemical peels, dermabrasion, microderabrasionLight sensitive medicationLoose, thin, aged skinLymphatic disorder, inflammation ofMedication, list here:Phlebitis, varicose veinsRecent accident or Serious injuryRecent surgical or dental procedureRosacea, telangiectasia/coupersoeRetin-A, RetinolSkin abrasions or lesionsStage III or IV acneSkin lightening or bleaching agentSunburnSwollen or infected tonsilsThyroid conditionsType 1 DiabeticOther contraindication at discretion of skincare technician or medical practitionerUnder medical care for an existing or suspected condition or diseaseViral infection, influenza, covid
If you answered YES to any of the above questions please explain
.My interest in skincare treatment is primarily for (i.e. skin rejuvenation, acne, hyperpigmentation, scarring, etc.)
Specify your areas of concern (i.e. eyes, forehead, etc.)
SECTION 2: CLIENT CONSENT FORM
Please mark that you have read each acknowledgement below:

I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months.I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two days after any aggressive facial exfoliation treatment.I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. The appearance of pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen.I acknowledge that my skin might experience temporary irritation, tightness, or redness which usually (initial here) dissipates within 72 hours depending on skin sensitivity.I have disclosed my history of allergies above.I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience allergic reactions.I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure, especially between 10am - 2pm.I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following the treatment.I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician and/or skincare practitioner during and following the treatment.I acknowledge that I am not pregnant/lactating.I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions.I acknowledge that I have answered all questions truthfully and completely.I release Edge Systems, the Aesthetician, management and staff of Healing Elements Day Spa from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products.I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name will not be used to identify these photographs without my written approval. By signing below, I certify that I have read and fully understood the contents of this consent form, and that the information I provided above are complete, accurate, and up-to-date to my knowledge.
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Hydrafacial

CLIENT CONSULTATION AND RELEASE FORM

SECTION 1: MEDICAL INFORMATION

SECTION 2: CLIENT CONSENT FORM