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Contact
Store
Home
About
Owner
Instructions/Q&A
Pre/Post HydraFacial Care
Pre/Post Sunless Tanning Care
Pre/Post Dermaplaning Care
Keravive Q & A
Services
Sunless Tanning
HydraFacial
HydraFacial Keravive
Facials and Peels
Celluma LED Therapy
Dermaplaning
Facial Waxing
Cosmedix Skincare
Forms
Spray Tan Consent Form
HydraFacial Consent Form
Cosmedix Health Intake
Keravive Consent Form
Peel Consent Form
Dermaplane Consent Form
COVID-19
Brides
Cancellation Policy
Contact
Store
HydraFacial Consultation & Consent Form
Forms
Spray Tan Consent Form
HydraFacial Consent Form
Cosmedix Health Intake
Keravive Consent Form
Peel Consent Form
Dermaplane Consent Form
COVID-19
HydraFacial Consent Form
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
How did you hear about us?
*
Search Engine (Google, Yahoo, etc.)
Instagram
Facebook
Other
Referral (List Name Below)
Referrals Name:
HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no 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:
1. Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity. 2. You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. 3. Client experiences may vary. Some clients may experience a delayed onset of these symptoms. 4. 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. 5. The skin is more susceptible to sunburn/sun damage. Avoid excessive exposure and use a minimum of SPF 40 sunscreen.
Do you have any of the following allergies?
Shellfish
Aspirin
Sulfur
Preservatives
Other, please list below:
Text Area
Skin Type
*
Normal
Oily
Dry/Dehydrated
Combination
Acne-Prone Skin
Sensitive
Mature
Areas of Concern
*
Fine Lines + Wrinkles
Elasticity + Firmness
Even Tone + Vibrancy
Skin Texture
Brown Spots
Oily + Congested Skin
Enlarged Pores
Do you have any of the following?
Active acne or infection?
*
Yes
No
Open lesion or cold sore
*
Yes
No
An active infection in the treatment area
*
Yes
No
Active sunburn
*
Yes
No
Skin conditions such as eczema, dermatitis, or rashes
*
Yes
No
An autoimmune disease such as lupus
*
Yes
No
A viral concern such as HIV or Hepatitis
*
Yes
No
Anticoagulants Therapy
*
Yes
No
Melanoma or lesions suspected of malignancy
*
Yes
No
Pregnancy or lactation
*
Yes
No
Neurological disorders such as epilepsy (LED Lights)
*
Yes
No
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic Drainage)
*
Yes
No
Crohn's Disease (Lymphatic Drainage)
*
Yes
No
Hyperthyroidism (Lymphatic Drainage)
*
Yes
No
Deep Venous Thrombosis (Lymphatic Drainage)
*
Yes
No
Lymphedema (Lymphatic Drainage)
*
Yes
No
Have you recently used Accutane, Topical medications, or Antibiotics
*
Yes
No
Have you recently had aesthetic fillers, injectables, or laser treatments
*
Yes
No
I acknowledge the following:
*
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 consent to have the HydraFacial treatment by the staff at Bare Bronze Beauty.
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 is valid for all future HydraFacial treatments. I will alert the staff if there are any future changes to my medical history.
Name 1
*
First Name
Last Name
Date
*
MM
DD
YYYY
Thank you!
