Hydrafacial Treatment Consent Form Your DetailsName(Required) First Name Last Name Email Enter Email Confirm Email PhoneThis field is hidden when viewing the formTreating Dentist NamePlease select your dentistDr Dennis Lee ChongDr. Mihir NanavatiKristina LimbuSasha VieiraThis field is hidden when viewing the formConsent Form Type(Required) Hydrafacial Consent This field is hidden when viewing the formHydrafacial Treatment ConsentInformed Consent for Hydrafacial Treatment ConsentDo you have any of the following?We want to ensure you get that glow and leave us looking and feeling radiant! To make sure you're suitable for treatment please check that none of the below apply to you. If any are a 'yes' your treatment provider will be evaluating your treatment options with you.Active acne or infection(Required) Yes No Open lesion or cold sore(Required) Yes No An active infection in the treatment area(Required) Yes No Active sunburn(Required) Yes No Skin conditions such as eczema, dermatitis, or rashes(Required) Yes No An autoimmune disease such as lupus(Required) Yes No A viral concern such as HIV or hepatitis(Required) Yes No Anticoagulants therapy(Required) Yes No Melanoma or lesions suspected of malignancy(Required) Yes No Pregnancy or lactation(Required) Yes No Neurological disorders such as epilepsy (LED Lights)(Required) Yes No Infection in the urinary system i.e. kidneys, bladder & urethra (Lymphatic drainage)(Required) Yes No Crohn's Disease (Lymphatic drainage)(Required) Yes No Hyperthyroidism (Lymphatic drainage)(Required) Yes No Deep Venous Thrombosis (Lymphatic drainage)(Required) Yes No Lymphedema (Lymphatic drainage)(Required) Yes No Have you recently?Used Accutane, Tretinoin/Retin-A, Hydroquinone, topical Meds or antibiotics within the last 6 months(Required) Yes No Using active skincare products such as Retinol, Benzoyl Peroxide, Azelaic Acid within 24hrs(Required) Yes No Experienced allergies (Shellfish, Aspirin)(Required) Yes No Had chemical peels, aesthetic fillers, injectables or laser treatments within the last 1 month(Required) Yes No Consent for photos (for own clinical records) Yes No Consent for photos for social media Yes No Tell us how we can help youI acknowledge the followingConsent(Required) 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 72 hours pre-and post-treatment.(Required)Consent(Required) The information provided has been explained to me and all my questions have been answered to my satisfaction. I understand that no guarantee or assurance can be given regarding the outcome of the treatment.(Required)Consent(Required) The information I have given is correct to the best of my knowledge, and I have not withheld any medical state or information.(Required)Consent(Required) By signing below, I acknowledge that I have read the above information and give my consent to be treated with the Hydrafacial System. I may at any time decline treatment even after giving my consent.(Required)Consent(Required) This consent form is valid for all future Hydrafacial treatments though I may withdraw my consent at any time. I will alert the staff if there are any future changes to my medical or health history.(Required)Signature(Required)Date(Required) DD slash MM slash YYYY
