Full Name: *

Date of Birth: *

Age: *

Phone Number: *

Email Address: *

Emergency Contact Name: *

Emergency Contact Phone: *

Medical History

Women only:

Are you pregnant, trying to conceive, or breastfeeding?

Yes

No

Medications & Skin Sensitivity

Are you currently taking any medications? (e.g., Accutane, antibiotics, blood thinners, steroids)

Yes

No

If yes, list:

Have you used any topical retinoids, exfoliants, or chemical peels in the past two weeks?

Yes

No

Do you have any allergies to skincare products or ingredients?

Yes

No

If yes, list:

Have you had recent cosmetic procedures (e.g., Botox, fillers, laser treatments)?

Yes

No

If yes, list:

Treatment Information & Risks

The HydraFacial is a non-invasive skin treatment that uses cleansing, exfoliation, extraction, and hydration to improve skin texture and appearance.

Possible side effects include but are not limited to: *

Temporary redness, sensitivity, or mild irritation.

Skin peeling or flaking after treatment.

Rare allergic reactions or breakouts.

Slight discomfort during extractions.

Contraindications:

HydraFacial is NOT recommended if you:

• Have active skin infections, cold sores, or open wounds.

• Have used Accutane within the past six months.

• Have had recent sunburn, laser treatments, or aggressive peels.

• Are allergic to salicylic acid, glycolic acid, or other facial ingredients.

Consent & Acknowledgment

I acknowledge that: *

I have disclosed all medical conditions, medications, and relevant history to the best of my knowledge.

I understand the potential risks, side effects, and healing process of HydraFacial treatments.

I have been informed that results vary from person to person and that multiple sessions may be needed.

I will follow all pre- and post-treatment care instructions provided to me.

I consent to the HydraFacial treatment and understand the risks involved.

Client Name (Print): *

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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