Reemake Skin Care Medical Spa & Laser Clinic

Reemake Skin Medical Spa + Laser Clinic

Consent Form

HydraFacial™ treatment Consent form

HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no 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:

Do you have any of the following?*
Active acne or infection YesNo
Open lesion or cold sore YesNo
An active infection in the treatment area YesNo
Active sunburn YesNo
Skin conditions such as eczema, dermatitis, or rashes YesNo
An autoimmune disease such as lupus YesNo
A viral concern such as HIV or hepatitis YesNo
Anticoagulants Therapy YesNo
Melanoma or lesions suspected of malignancy YesNo
Pregnancy or lactation YesNo
Neurological disorders such as epilepsy (LED Lights) YesNo
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage) YesNo
Crohn’s Disease (Lymphatic drainage) YesNo
Hyperthyroidism (Lymphatic drainage) YesNo
Deep Venous Thrombosis (Lymphatic drainage) YesNo
Lymphedema (Lymphatic drainage) YesNo
Have you recently?
Used Accutane, topical medications or antibiotics YesNo
Had aesthetic fillers, injectables or laser treatments YesNo
I acknowledge the following: