Spa Me Now - Hydrafacial Consent Form

Spa Me Now - Hydrafacial Consent Form
HydraFacial is the only hydradermabrasion 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*

YesNo
Open lesion or cold sore*

YesNo
An active infection in the treatment area*

YesNo
Active sunburn*

YesNo
Skin conditions such as eczema, dermatitis, or rashes*

YesNo
An autoimmune disease such as lupus*

YesNo
A viral concern such as HIV or hepatitis*

YesNo
Anticoagulants Therapy*

YesNo
Melanoma or lesions suspected of malignancy*

YesNo
Pregnancy or lactation*

YesNo
Neurological disorders such as epilepsy (LED Lights)*

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

YesNo
Crohn’s Disease (Lymphatic drainage)*

YesNo
Hyperthyroidism (Lymphatic drainage)*

YesNo
Deep Venous Thrombosis (Lymphatic drainage)*

YesNo
Lymphedema (Lymphatic drainage)*

YesNo
*Saying yes does not preclude you from receiving treatments.
Have you recently?
Used Accutane, topical medications or antibiotics*

YesNo
Had aesthetic fillers, injectables or laser treatments*

YesNo
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 Spa Me Now.
- 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.
Please confirm*

I have read and understand the above information
Name*

First NameLast Name
Client Signature*

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Spa Me Now - Hydrafacial Consent Form

What to expect:

Do you have any of the following?

Have you recently?