HydraFacial Consent Form

HydraFacial is the only hydra dermabrasion procedure 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

Open lesion or cold sore

Yes

An active infection in the treatment area

Yes

Active sunburn

Yes

Skin conditions such as eczema, dermatitis, or rashes

Yes

An autoimmune disease such as lupus

Yes

A viral concern such as HIV or hepatitis

Yes

Anticoagulants Therapy

Yes

Melanoma or lesions suspected of malignancy

Yes

Pregnancy or lactation

Yes

Neurological disorders such as epilepsy (LED Lights)

Yes

Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)

Yes

Crohn’s Disease (Lymphatic drainage)

Yes

Hyperthyroidism (Lymphatic drainage)

Yes

Deep Venous Thrombosis (Lymphatic drainage)

Yes

Lymphedema (Lymphatic drainage)

Yes

Have you recently?

Used Accutane, topical medications or antibiotics

Yes

Had aesthetic fillers, injectables or laser treatments

Yes

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 Allure Beauty and Aesthetics.
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.

Patient Signature

Patient Name

Date / Time

HydraFacial Consent Form

HydraFacial Consent Form

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