HydraFacial® Release Form

Date of Appointment*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Section 1: Medical Information

Accutane or other similar medication (in the past year)*

Autoimmune disease, HIV, lupus, hepatitis, scleroderma*

Active Infection in the treatment area*

Melanoma or lesions suspected of malignancy*

Active Sunburn*

Pregnancy (medical-legal)*

How Far Along Are You?

What is Your Due Date?

Breast feeding (medical-legal, may increase skin sensitivity & likelihood of PIH)*

Epilepsy contraindicated for LED light therapy*

Anticoagulants therapy (use lower settings)*

Very thin skin*

Other Aesthetic Treatments: Botox: wait 5-7 days; Fillers: wait 7-10 days; Peels: wait 30 days*

Laser Treatments: wait until lesions heal & swelling & redness is resolved*

Keloids: avoid direct contact*

Rosacea, telangiectasia (use lower vacuum)*

Unrealistic expectations*

If you answered YES to any of the above questions please explain:

Please list any known allergies:

Section 2: Client Consent Form

1. I acknowledge that my skin might experience temporary irritation, tightness, or redness, which usually dissipates within 72 hours depending on skin sensitivity.*

I acknowledge

2. I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure, especially between 10 am - 2 pm.*

I acknowledge

3. I have disclosed my history of allergies above and I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience an allergic reaction.*

I acknowledge

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

I acknowledge

5. I acknowledge that I have answered all questions truthfully and completely.*

I acknowledge

6. I release Edge Systems, the Aesthetician, management and staff of Jinsei Spa from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products.*

I acknowledge

7. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name wwill not be used to identify these photographs without my written approval.*

I acknowledge

By signing below, I certify that I have read and fully understood the content of this consent form, and that the information I provided above are complete, accurate, and up-to-date to my knowledge.

E Signature (type your name here)*

Date*

Below this line for Jinsei Spa use only

Operator Signature

Date