HydraFacial consultation and consent form HydraFacial consultation and consent form Please read carefully, complete, sign and date this form prior to your treatment. How did you hear about us? Full Name Date of Birth Address Contact Number Email Select your treatment Perk TreatmentHydraFacial Treatment Medical Information: This section of medical conditions should not be treated either straight away OR until the condition resolves itself or not at all with Perk/HydraFacial Do any of the following conditions relate to you? Please tick the appropriate box. Roaccutane or Accutane within the last 6 monthsYesNo Allergy to shellfishYesNo Allergy to asprin or honey; (HydraFacial only)YesNo Any other allergies/intolerancesYesNo If yes, specify allergies Autoimmune disorders (HIV, Lupus, Hepatitis, etc.)YesNo PregnancyYesNo BreastfeedingYesNo Cancer or history of cancerYesNo If yes, please specify Cold sores within the last monthYesNo Cosmetic injections within the last 2 weeksYesNo Recent laser procedures in the treatment areaYesNo Recent deep chemical peels in the treatment area YesNo Facial waxing with last 2 weeks YesNo Retin A or Retinol products YesNo Active eczema on the treatment site YesNo Open wounds on the treatment site YesNo Fresh scars on the treatment site YesNo HydraFacial Section Only: This section of medical conditions can be treated with lower vacuum settings and without the LED light for patients on light sensitive medication and with epilepsy. Blood thinners YesNo Cortisone or steroid injections YesNo Epilepsy YesNo Light sensitive medication YesNo Diabetic YesNo Please specify here any other medical conditions we may need to be aware of. CLIENT DECLARATION: I have answered and understood the above medical questionnaire to the best of my knowledge and all information provided is correct. I give permission for to carry out the Perk/HydraFacial (insert protocol) treatment on myself and have read and understood the information about the treatment and the risks associated. 1. I acknowledge that I am not pregnant or breast feeding, haven’t used Roaccatune within the last 6 months, haven’t received any cosmetic injections with the last 2 weeks, I don’t suffer from cancer and autoimmune disorders and do not have any known allergies to shellfish. I have specified any other allergies I have in the medical questionnaire form. 2. I have been given a full consultation and explanation of the Perk/HydraFacial treatment and all my questions are answered. 3. I acknowledge that there is no guarantee to the results of the treatments and acknowledge the need for the continual care for the extension of treatment results. 4. I acknowledge that it is my responsibility to use a minimum of SPF 30 following my treatment. 5. I understand that there may be skin reactions to the ingredients or the treatment itself, and skin may experience temporary irritation,tightness, redness, itchiness and swelling. All of these affects will resolve themselves within days to weeks depending on the skin sensitivity. 6. I understand that it is my responsibility to avoid Retinol, Retin-A products pre and post Perk/HydraFacial treatmentsfor a minimum of 2 days. 7. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. 8. I consent to the use of my before, during and after facial procedure photos for education and promotional purposes. 9. I am ok to receive from time to time information with marketing messages, special offers and other information. This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.