HydraFacial Consent Form - Qaya Clinic - HydraFacial & Hijama Cupping Birmingham

HydraFacial Consent Form

A copy of this completed consent form along with post treatment advice will be emailed to the email address you provide below.

This section of medical conditions should not be treated either straight away OR until the condition resolves itself or not at all.
Do any of the following conditions relate to you? Roaccutane of Accutane within the last 6 months YesNo Allergy to shellfish YesNo Allergy to aspirin or honey YesNo Any other allergies / intolerances; Please specify Autoimmune disorders (HIV, Lupus, Hepatitis, etc.) YesNo Pregnancy YesNo Breastfeeding YesNo Cancer or history of cancer; Please specify Cold sores within the last month YesNo Cosmetic injections within the last 2 weeks YesNo Recent laser procedures in the treatment area YesNo Recent deep chemical peels in the treatment area YesNo Facial waxing within last 2 weeks YesNo Retin A or Retinol products YesNo Active eczema on the treatment site YesNo Open wounds on the treatment site YesNo Fresh scars on the treatment site YesNo HydraFacial Section Only:
This section of medical conditions can be treated with lower vacuum settings and without the LED light for patients on light senstive medication and with epilepsy. Blood thinners YesNo Cortisone or sterioid injections YesNo Epilepsy YesNo Light sensitive medication YesNo Diabetic YesNo Notes: Please specify here any other medical conditions we may need to be aware of

I acknowledge that I am not pregnant or breast feeding, haven't used Roaccatune within the last 6 months, haven't received any cosmetic injections within the last 2 weeks, I don't suffer from cancer and autoimmune disorders and do not have any known allergies to shellfish. I have specified any other allergies I have in the medical questionnaire form.

I have been given a full consultation and explanation of the HydraFacial / Perk treatment and all my questions are answered.

I acknowledge that there is no guarantee to the results of the treatments and acknowledge the need for the continual care for the extension of treatment results.

I acknowledge that it is my responsibility to use a minimum of SPF 30 following my treatment.

I understand that there may be skin reactions to the ingredients or the treatment itself, and skin may experience temporary irritation, tightness, redness, itchiness and swelling. All of these affects will resolve themselves within days to weeks depending on the skin sensitivity.

I understand that it is my responsibility to avoid Retinol, Retin-A products pre and post HydraFacial / Perk treatments for a minimum of 2 days.

I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions.

I have answered and understood the above medical questionnaire to the best of my knowledge and all information provided is correct.

I consent to the use of my before, during and after facial procedure photos for education and promotional purposes YesNo Your Signature:

Practitioner Signature:

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