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HydraFacial® Release Form
Name
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First
Middle
Last
Phone
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Email
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Referred By
Service Being Conducted
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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)
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Yes
No
Autoimmune disease, HIV, lupus, hepatitis, scleroderma
*
Yes
No
Active Infection in the treatment area
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Yes
No
Melanoma or lesions suspected of malignancy
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Yes
No
Active Sunburn
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Yes
No
Pregnancy (medical-legal)
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Yes
No
Breast feeding (medical-legal, may increase skin sensitivity & likelihood of PIH)
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Yes
No
Epilepsy contraindicated for LED light therapy
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Yes
No
Relative Contraindications
Anticoagulants therapy (use lower settings)
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Yes
No
Very thin skin
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Yes
No
Other Aesthetic Treatments: Botox: wait 5-7 days; Fillers: wait 7-10 days; Peels: Wait 30 days
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Yes
No
Laser Treatments: wait until lesions heal & swelling & redness is resolved
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Yes
No
Other Concerns
Keloids: avoid direct contact
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Yes
No
Rosacea, telangiectasia (use lower vacuum)
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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
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I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions
initial
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I acknowledge that I have answered all questions truthfully and completely.
initial
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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
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Client’s Signature
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Esthetician's Printed Name
*
Esthetician's Signature
*
Today's Date
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Talk with one of our skincare specialist and get answers to any questions you have about your skincare routine or treatments we offer here at Allure Skincare and Lash.
(720) 550-7953
info@allureskincareandlash.com
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