Hydrafacial Consent FormName*Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Email* HydrafacalBlue LED Light TherapyRed LED Light TherapyLymphatic / Massage TherapyWet Diamond (Medical Use Only)MicrodermabrasionSection 1: Do any of the following conditions relate to you?Do you have any of the following allergies?*ShellfishAspirinSulfurPreservativesOtherIf other, please describeYes to any of the following Contraindications?Accutane or other similar medicationAutoimmune disease, HIV, lupus, hepatitisBlood thinners – Heparin, Coumadin, Warfarin, etc.Breast feeding, pregnancyCancer or post-cancer treatmentsCardiovascular problemsCold sores or fever blisters without pre-medicationCortisone or steroid injectionsCosmetic injections, fillers or implants, (i.e. Botox®, collagen)Eczema, psoriasisEnlarged or painful glandsEpilepsyFacial waxing services w/in 7-14 daysHeart ailmentHypertension/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, microdermabrasionLight sensitive medicationLoose, thin, aged skinLymphatic disorder, inflammation of lymph vessels, lymphedemaMedication, list here:Pacemaker or metal implantsPhlebitis, varicose veinsRecent accident or serious injuryRecent surgical or dental procedureRosacea, telangiectasia/couperoseRetin-A, RetinolSkin abrasions or lesionsStage III or IV acneSkin-lightening or bleaching agentSunburnSwollen or infected tonsilsThyroid conditionsType I diabeticUnder medical care for an existing or suspected condition or diseaseViral infection, influenzaOther 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 ___________________CAPTCHACommentsThis field is for validation purposes and should be left unchanged.