HydraFacial® Release Form

Name*

First Middle Last

Phone*

Email*

Referred By

Service Being Conducted*

Select All
HYDRAFACIAL®
BLUE/RED LED LIGHT THERAPY
LYMPHATIC/MASSAGE THERAPY
MICRODERMABRASION
WET DIAMOND

Absolute Contraindications

Accutane or other similar medication (in the past year)*

Yes
No

Autoimmune disease, HIV, lupus, hepatitis, scleroderma*

Yes
No

Active Infection in the treatment area*

Yes
No

Melanoma or lesions suspected of malignancy*

Yes
No

Active Sunburn*

Yes
No

Pregnancy (medical-legal)*

Yes
No

Breast feeding (medical-legal, may increase skin sensitivity & likelihood of PIH)*

Yes
No

Epilepsy contraindicated for LED light therapy*

Yes
No

Relative Contraindications

Anticoagulants therapy (use lower settings)*

Yes
No

Very thin skin*

Yes
No

Other Aesthetic Treatments: Botox: wait 5-7 days; Fillers: wait 7-10 days; Peels: Wait 30 days*

Yes
No

Laser Treatments: wait until lesions heal & swelling & redness is resolved*

Yes
No

Other Concerns

Keloids: avoid direct contact*

Yes
No

Rosacea, telangiectasia (use lower vacuum)*

Yes
No

Unrealistic expectations*

Yes
No

If you answered YES to any of the above questions please explain:

Please list any known allergies:

Client Consent

(Initial each acknowledgement line below)

I acknowledge that my skin might experience temporary irritation, tightness, or redness, which usually dissipates within 72 hours depending on skin sensitivity.

initial*

I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure.

initial*

I have disclosed my history of allergies above and I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience an allergic reaction.

initial*

I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness, although uncommon, should the tint enter into the eye.

initial*

I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions

initial*

I acknowledge that I have answered all questions truthfully and completely.

initial*

I release the Aesthetician/Doctor, management and staff of Allure Skincare and Lash from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products

initial*

I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name will not be used to identify these photographs without my written approval.

initial*

By signing below, I certify that I have read and fully understood the contents of this consent form, and that the information I provided above are complete, accurate, and up-to-date to my knowledge.

If you experience any issues or complication after the conclusion of your appointment you must contact the office or your esthetician within 72hrs of your appointment.

Client’s Printed Name*

Client’s Signature*

Esthetician's Printed Name*

Esthetician's Signature*

Today's Date*