Hydrafacial Consent Form Name* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Email* Hydrafacal Blue LED Light Therapy Red LED Light Therapy Lymphatic / Massage Therapy Wet Diamond (Medical Use Only) Microdermabrasion Section 1: Do any of the following conditions relate to you?Do you have any of the following allergies?* Shellfish Aspirin Sulfur Preservatives Other If other, please describe Yes to any of the following Contraindications? Accutane or other similar medication Autoimmune disease, HIV, lupus, hepatitis Blood thinners – Heparin, Coumadin, Warfarin, etc. Breast feeding, pregnancy Cancer or post-cancer treatments Cardiovascular problems Cold sores or fever blisters without pre-medication Cortisone or steroid injections Cosmetic injections, fillers or implants, (i.e. Botox®, collagen) Eczema, psoriasis Enlarged or painful glands Epilepsy Facial waxing services w/in 7-14 days Heart ailment Hypertension/high blood pressure Inflammatory conditions Irregular, pigmented moles, warts or growths, unidentified facial growth or mark Keloids, pigmented scars, icepick scars, new scar tissue Laser procedures, chemical peels, dermabrasion, microdermabrasion Light sensitive medication Loose, thin, aged skin Lymphatic disorder, inflammation of lymph vessels, lymphedema Medication, list here: Pacemaker or metal implants Phlebitis, varicose veins Recent accident or serious injury Recent surgical or dental procedure Rosacea, telangiectasia/couperose Retin-A, Retinol Skin abrasions or lesions Stage III or IV acne Skin-lightening or bleaching agent Sunburn Swollen or infected tonsils Thyroid conditions Type I diabetic Under medical care for an existing or suspected condition or disease Viral infection, influenza Other contraindication at discretion of skincare technician or medical practitioner: 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 1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months. 2. 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. 3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen. 4. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within72 hours depending on skin sensitivity. 5. I have disclosed my history of allergies above. 6. I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience allergic reactions. 7. 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. 8. I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. 9. 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. 10. 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. 11. I acknowledge that I am not pregnant/lactating. 12. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. 13.I acknowledge that I have answered all questions truthfully and completely. 14. I release Edge Systems, the (Aesthetician/Doctor), management and staff of (Clinic/Office) from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products. 15. 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. Date* MM slash DD slash YYYY Untitled* I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure. Staff signature ___________________ Patient signature ___________________ CAPTCHANameThis field is for validation purposes and should be left unchanged.
