Client Consultations Keeping Your Skin Treatment Safe Client ConsultationPlease read carefully, complete, sign and date this form prior to your treatment.First Name *Last NameEmail Address *Phone NumberDate of BirthTreatment RequiredDo any of the following conditions relate to you?Roaccutane or Accutane within the last 6 monthsYesNoAllergy to shellfishYesNoAllergy to asprin or honey; (HydraFacial only) YesNoAutoimmune disorders (HIV, Lupus, Hepatitis, etc.)YesNoPregnancyYesNoBreastfeedingYesNoCancer or history of cancerYesNoCold sores within the last monthYesNoCosmetic injections within the last 2 weeksYesNoRecent laser procedures in the treatment areaYesNoRecent deep chemical peels in the treatment areaYesNoFacial waxing with last 2 weeksYesNoRetin A or Retinol productsYesNoActive eczema on the treatment siteYesNoOpen wounds on the treatment siteYesNoFresh scars on the treatment siteYesNoHydraFacial Section Only - This section of medical conditions can be treated with lower vacuum settings and without LED light for patients who are light sensitive.Blood thinnersYesNoCortisone or steroid injectionsYesNoEpilepsyYesNoLight sensitive medicationYesNoDiabeticYesNoDo you I consent to the use of my before, during and after facial procedure photos for education and promotional purposes?YesNoGDPR *From time to time we would like to contact you with marketing messages, special offers and other information. If you are happy to receive this information tick this box. Do you agree with the below:1. 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 with 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.2. I have been given a full consultation and explanation of the Perk/HydraFacial treatment and all my questions are answered. 3. 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. 4. I acknowledge that it is my responsibility to use a minimum of SPF 30 following my treatment. 5. 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 effects will resolve themselves within days to weeks depending on the skin sensitivity. 6. I understand that it is my responsibility to avoid Retinol, Retin-A products pre and post Perk/HydraFacial treatments for a minimum of 2 days. 7. I hereby agree to have the treatment performed and agree to follow all pre and post-treatment instructions.Client Signature *Start signing your signature hereYour browser does not support e-Signature field.Date Send MessagePlease do not fill in this field.