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 HydraFacial before? *

Yes

No

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

Are you allergic to any skincare ingredients, shellfish, aspirin, or glycolic acid? *

Yes

No

Please list :

Have you had any recent sunburns, waxing, or exfoliation treatments within the past 72 hours? *

Yes

No

Are you planning to have Botox or fillers in the next 2 weeks? *

Yes

No

Risks, Side Effects, and Acknowledgements

Please read and initial each statement regarding HydraFacial: *

I understand HydraFacial is a non-invasive procedure that exfoliates, hydrates, and infuses the skin.

I acknowledge that results vary based on individual skin type and condition.

I understand potential temporary side effects include redness, tingling, tightness, breakouts, or flaking.

I will notify the technician of any discomfort or adverse reaction during or after treatment.

I agree to follow all pre- and post-care instructions to maximize results and minimize risks.

I understand that sun exposure should be avoided before and after the treatment.

I consent to photographs taken for clinical documentation purposes.

Client Declaration and Consent

I confirm I have disclosed my full medical history, current medications, and skincare use.

I have read and understood the nature of the HydraFacial treatment, benefits, and risks.

All questions were answered to my satisfaction, and I voluntarily consent to receive the 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.

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HydraFacial – Comprehensive Consent and Concern Form

Skin Concerns & Goals

Treatment Information & Contraindications

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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