HydraFacial Consultation and Consent Form

 

    HydraFacial consultation and consent form

    Please read carefully, complete, sign and date this form prior to 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.

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    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.

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo



    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.

     

     

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    IG3 9LD

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