HYDRAFACIAL CLIENT CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

I understand:

• The goal of HydraFacial is to deep cleanse and hydrate facial skin with improvement in skin tones and texture, acne breakouts and general skin health. Every individual is unique and it is very difficult to guarantee a specific number of treatments needed. Results vary with the individual and in the case of acne and sun damage depend on the amount of acne and compliance with recommended adjunctive measures and skincare. HydraFacial treatments are recommended every two to three months for optimal results and any time before special events.

• Common side effects such as slight redness usually subside within a few hours after treatment.

• Uncommon side effects such as bruising, skin irritation and exacerbation of skin breakout can occur.

• Rarely, allergic reaction, pigment changes of freckles, moles or skin such as hypo pigmentation (lightening) or hyper pigmentation (darkening) can occur and may resolve, but can be permanent. Scarring and textural changes are also rare side effects but can result from this procedure. There may be risks not yet known at this time.

• Side effects can worsen with sun exposure and daily use of a good quality SPF is very important and highly recommended.

• I will inform the technician, nurse or physician if my medical condition changes over the course of treatment.

• The risk of side effects increases with other medical conditions such as immunocompromised conditions (diabetes, HIV, being on immune suppressants such as prednisone) that can be associated with poor skin healing and increased risk of infection. None of these conditions apply to me.

• Every person is unique and although good results are expected, it is impossible to guarantee.

I have read and understood this HydraFacial Consent Form. My questions have been answered satisfactorily by the doctor, nurse or technician. I accept the risks and complications of the procedure.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :