Hydrafacial Consultation and Consent Form

Client Details

Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do any of the following apply to you? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Pre-Treatment Guidance

Don’t use any exfoliating treatments, like glycolic acid or enzymes, on the area that is going to be treated for at least 48 hours before your treatment.
Stop using any medium or deep chemical peels or chemical resurfacing treatments and laser treatments for at least 2 weeks before you have this facial treatment.
Do not wax or use depilatories for at least 48 hours before your treatment.
Stop using any over-the-counter acne medications, like benzoyl peroxide and salicylic acid, for at least 48 hours before you have your facial.
Avoid any excessive sun exposure and do not use any tanning beds for at least 72 hours before treatment.
Do not have any Botox treatments for at least 2 weeks before treatment. You can have Botox done on the same day as your facial, but it must happen after the facial.
Do not shave your face on the same day as the facial treatment.

Treatment Information

What is a HydraFacial?

A HydraFacial is a patented skin treatment. It’s also sometimes called “hydradermabrasion” because it involves microdermabrasion-like exfoliation paired with hydrating serums.

Known for its three-step process, the HydraFacial works to deep-clean, exfoliate, and hydrate your skin. This procedure may help treat a variety of skin conditions, including acne, dryness, and wrinkles.

The noninvasive procedure is similar in principle to a regular facial but can provide more dramatic results. This is achieved by a mechanized wand used on your skin to deeply clean and exfoliate while delivering serums customized to your skin type.

The HydraFacial is said to help improve overall skin texture, tone, and appearance. This is due to the deep exfoliation that cleans your pores, removing debris and allowing for better penetration of face serums tailored to your skin type.

How does it work?

A vortex-like wand is used against your skin to help clear away dirt and oil from deep in your pores. We may also use a peel to help exfoliate and resurface your skin.
Next, a vacuum-like attachment on the wand is used to help extract debris from your pores.
Finally, we will use a pen-like attachment to apply a moisturizing serum with antioxidants.

Aftercare Advice

Avoid extra sun exposure and don’t use any tanning beds for at least 72 hours after the treatment.
Apply SPF 30 sunscreen daily for at least 5 days after the treatment.
Avoid touching your face for 24 hours after the treatment. The morning after the treatment you may wash your face with a very gentle cleanser.
Don’t use topical Retin-A or generic tretinoin for at least 48 hours after treatment.
Do not wax or use depilatories for at least 48 hours after the treatment.
Don’t use any medium or deep chemical peels or laser treatments for at least 2 weeks after your facial treatment.
Don’t use any exfoliating treatments, like glycolic acid or enzymes, for at least 48 hours after the treatment.
Don’t use over-the-counter acne medications, like benzoyl peroxide or salicylic acid, for at least 48 hours after treatment.
Avoid intense heat (e.g. hot bath/shower, exercise, sauna etc.) for at least 48 hours after treatment.
Wait 24 hours before applying makeup. When you do apply makeup ensure your brushes have been thoroughly cleansed to avoid infection.

Please tick the box to confirm: *

I have read and understood the aftercare advice provided to me on this form.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Hydrafacial treatment.

Client Signature: *

Tap or click on the signature above to sign