HydraFacial Consent Form Name * First Name Last Name Date of birth MM DD YYYY Are you currently experiencing any of the following with your skin? * Acne vulgaris (stage 3-4) Active sunburn Bacterial/fungal infections Dermatitis Herpes simplex (cold sores) Papulopustular rosacea Open lesions or skin infection Skin cancer Warts NONE OF THE ABOVE OTHER Please specify if you have ticked 'OTHER' Are you under supervision for any of the following? * Anticoagulants/blood thinners Auto-immune disorder Cancer Cardiac conditions/ Arrhythmia Crohn's Disease Deep Venous Thrombosis Melanoma or lesions suspected of malignancy Hepatitis Human immunodeficiency virus (HIV) Hyperthyroidism Isotretinoin (including but not limited to Roaccutane/Accutane/Isotane) Neurological disorders Lymphedema Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics) Pregnant, lactating or trying Pseudo cholinesterase deficiency NONE OF THE ABOVE OTHER Please specify if you have ticked 'OTHER' In the last 2 weeks, have you had any of these treatments? * Only in relation to areas that will be treated with skin needling Anti-wrinkle injections (ie. Botox, Dysport etc.) Chemical Peel (ie. Glycolic acid, lactic acid, salicylic acid etc.) Dermabrasion (ie. Hydrodermabrasion, microdermabrasion) Derma blading/ Derma planing Electrolysis Fillers (ie. Juvederm, Restylane, Sculptra etc.) Hair removal (ie. Depilatory cream, plucking, sugaring, threading, waxing etc.) Laser/IPL Plastic/Cosmetic surgery Radio frequency (RF) Spray/self-tan Sun tan/solarium Tattoo/cosmetic tattoo NONE OF THE ABOVE In the last week, have you used any products containing any of the following ingredients? * Only in relation to areas that will be treated with skin needling AHA/BHA (ie. Glycolic acid, lactic acid, salicylic acid) Azelaic acid/Kojic acid Benzoyl peroxide Hydroquinone Retinoids/Vitamin A (Adapalene, tretinoin, retinol) NONE OF THE ABOVE Do you have any known allergies? Food/liquids/materials/medication * (Eg. Latex, materials, shellfish, nuts, penicillin, anaesthetic agents, P-aminobenzoic acid (PABA), sulphonamide allergies) Consent for treatment * I hereby have completed Dermal Edit's Skin consultation form and HydraFacial Consent form honestly and to the best of my knowledge about myself, my skin and medical background. My treatment provider for HydraFacial has provided me with all pre-treatment and post-treatment information, and has verbally explained to me all that entails for a HydraFacial treatment. I accept full responsibility for my pre and post care and understand that a course of HydraFacial treatments are required for optimum results. By signing this form, I understand all information given to me, give my consent and will alert of any future changes to my medical history. Today's date * MM DD YYYY Thank you!
