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Hydrafacial Treatment Consent Form

Collects a signed authorization before a Hydrafacial session begins. Clients confirm contact details, flag skin conditions that may rule out the procedure, and disclose allergies plus any medication they take. Designed for aesthetic clinics, dermatology offices and facial care studios.

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Name

Birthday

Address

City

State/Province

Zip/Postal code

Phone #

Emergency Contact

Emergency contact #

Medical and skin history

Active Acne

Active Infection

Open Lesion/Cold Sore

Active Sunburn

Eczema, Dermatitis or Rashes

Autoimmune Disease

HIV

Hepatitis

Type of hepatitis

Hepatitis A Hepatitis B Hepatitis C None

Melanoma

Lesions suspected of Malignancy

Pregnant or Lactating

Epilepsy

Neurological Disorder

Lupus

Keloids

Rosacea or Telangiectasia

Do you have any Allergies?

Latex Fragrances or cosmetics Medication Food No known allergies

No known allergies

Current medication

Are you currently taking any medications including over the counter, prescribed, topical, supplements and vitamins?

Yes No

Please give details below

Yes, please list ALL medications you are currently taking

Have you recently used Accutane, Topical Medications or Antibiotics?

Yes No

No, I have not used any of these

If Yes, please list

Previous facial treatments

Yes, I have had facial treatments before

Have you had an adverse reaction to a facial treatment?

Yes No

If Yes, please specify

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