HydraFacial Consultation and Consent Form HydraFacial consultation and consent formPlease 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 Which practice would you like to contact? IllfordHornchurchSelect your treatment Perk TreatmentHydraFacial TreatmentMedical 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/HydraFacialDo any of the following conditions relate to you? Please tick the appropriate box. Roaccutane or Accutane within the last 6 monthsYesNoAllergy to shellfishYesNoAllergy to asprin or honey; (HydraFacial only)YesNoAny other allergies/intolerancesYesNo If yes, specify allergies Autoimmune disorders (HIV, Lupus, Hepatitis, etc.)YesNoPregnancyYesNoBreastfeedingYesNoCancer or history of cancerYesNo If yes, please specify Cold sores within the last monthYesNoCosmetic injections within the last 2 weeksYesNoRecent laser procedures in the treatment areaYesNoRecent deep chemical peels in the treatment area YesNoFacial waxing with last 2 weeks YesNoRetin A or Retinol products YesNoActive eczema on the treatment site YesNoOpen wounds on the treatment site YesNoFresh scars on the treatment site YesNoHydraFacial 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 YesNoCortisone or steroid injections YesNoEpilepsy YesNoLight sensitive medication YesNoDiabetic YesNoPlease specify here any other medical conditions we may need to be aware of. Next of kin Full Name Relationship to Patient Contact Number GP Details GP Name Practice Name GP Contact Number 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.
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