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Home
About
- About Us
- Staff
Services
Specials
Products
Your Visit
Forms
Careers
Social
Contact

Call / Text:913-441-9090
clients@lavitabelladayspa.com

Forms

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Home › Forms › Hydrafacial Treatment Consent Form

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

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 in the last 6 months:*

Yes No

Had Aesthetic Fillers, Injectables or Laser Treatments in the last 10 days:*

Yes No

Had Any Medical Grade Peels in the last 30 days:*

Yes No

Additional Information / Comments

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 my consent to have the Hydrafacial treatment by the staff

:*

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

Name:*

Email:*

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La Vita Bella Day Spa
5416 Roberts Street
Shawnee, KS
clients@lavitabelladayspa.com

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913-441-9090

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