HydraFacial – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details: *

Are you currently taking any medications or supplements (oral or topical)? *

Yes

No

Are you currently using Retin-A, Accutane, or any topical acne treatments? *

Yes

No

If yes, please let us know: *

Are you pregnant or trying to conceive? *

Yes

No

Are you currently breastfeeding? *

Yes

No

Have you had any recent cosmetic procedures (laser, fillers, peels, microneedling)? *

Yes

No

Please describe and include dates : *

Skin Concerns & Goals

What are your skincare objectives? *

Which products are you currently using? *

Treatment Information & Contraindications

Have you had a chemical peel before? *

Yes

No

If so, when did it happen and what was your experience? *

Have you experienced any allergic reactions to skincare products in the past ? *

Yes

No

Do you currently have any cuts, open wounds, or active skin infections in the area to be treated *

Yes

No

Have you had recent sun exposure or tanning (natural or artificial)? *

Yes

No

Risks, Side Effects, and Acknowledgements

Please read and initial each statemen regarding Chemical Peel Facial:

I understand that chemical peels are designed to exfoliate the skin and promote new cell growth.

I acknowledge that temporary side effects may include redness, flaking, stinging, tightness, and increased sensitivity.

I understand that the intensity of the peel and downtime varies based on the type of peel and my skin's condition.

I understand that results may vary and multiple treatments may be required for optimal results.

I agree to avoid sun exposure, active products, makeup, and exercise for the time period advised by my practitioner.

I will notify the clinic of any side effects or concerns that occur following treatment.

I understand that chemical peels are not suitable for all skin types or conditions and that my skin may react differently.

Client Declaration and Consent

I confirm the information provided is accurate and complete to the best of my knowledge.

I have had the opportunity to ask questions and all were answered to my satisfaction.

I understand the nature of the chemical peel treatment, its risks, benefits, and alternatives.

I voluntarily consent to receive chemical peel treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

Privacy Policy | Imprint

Privacy Policy Imprint Our Services

Designed by Metanow

HydraFacial – Comprehensive Consent and Concern Form

Skin Concerns & Goals

Treatment Information & Contraindications

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

Idens Laser Clinic Aesthetics © All rights reserved