Intake Facial

Date

First Name

Last Name

Street Address

APT/ Suite

City

State

Zip Code

Phone

Date of Birth

Gender

How did you hear about us? How did you hear about us?

Which treatment are you interested in having?

HydraFacial

Facial

Not Sure

OtherOther

What are your expectations and goals of this treatment?

Do you have any of the following?

Open Lesion or cold sore

Yes

OtherOther

Active acne or infection

Yes

OtherOther

An active infection in the treatment area

Yes

OtherOther

Active sunburn

Yes

OtherOther

Skin condition such as eczema, dermatitis, or rashes

Yes

OtherOther

An autoimmune disease such as lupus

Yes

OtherOther

A viral concern such as HIV herpatitis

Yes

OtherOther

Anticoagulants Therapy

Yes

OtherOther

Melanoma or lesions suspected of malignancy

Yes

OtherOther

Pregnancy or lactation

Yes

OtherOther

Neurological disorders such as epilepsy (LED Lights)

Yes

OtherOther

Infection in the urinary systems i.e. kidneys, bladder and urethra (Lymphatic Drainage)

Yes

OtherOther

Chron's disease (Lymphatic Drainage)

Yes

OtherOther

Hypervehyroidism (Lymphatic Drainage)

Yes

OtherOther

Deep venous thrombosis (Lymphatic Drainage)

Yes

OtherOther

Lymphedema (Lymphatic Drainage)

Yes

OtherOther

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HydraFacial What to Expect

Hydrafacial is the only hydradermabrasion treatment that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-tono downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from Hydrafacial will vary from person to person.

What to expect:

Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions
that typically resolve within 72 hours depending on skin sensitivity.

You may experience tingling and stinging in the treatment area. These sensations generally subside
within a few hours.
Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen

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HydraFacial What to expect

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HydraFacial Terms and Conditions

I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols
that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks
pre-and post-treatment.

Photos may be taken before, during and after the Hydrafacial treatment. Photos will only be used with
my written approval for education, promotion or advertising purposes.

The information provided has been explained to me and all my questions have been answered to
my satisfaction. I have read the above information, and I give my consent to have the Hydrafacial
treatment by the staff at Elite Spa (Elite Rejuvenation Center INC) .
By signing below, I acknowledge that I have read the above information and give my consent to be
treated with the Hydrafacial System. This consent form Is valid for all future Hydrafacial treatments.
I will alert the staff If there are any future changes to my medical history.

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HydraFacial Terms and Conditions

I acknowledge I read and agree

I disagree

I have read the information above, I understand and accept this informed consent.

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Facial Consent Forms

Do you have any of the following?

HydraFacial What to Expect

HydraFacial Terms and Conditions