Please read carefully, complete, sign and date this form prior to your treatment. 

Name: __________________________________ Phone: (___)_________ 
	HYDRAFACIAL ™ with Hyaluronic-$99		HYDRAFACIAL ™ with DermaBuilder  $125	
	HYDRAFACIAL ™ with GySal  1.5% or 7.5% $125		HYDRAFACIAL ™ with TNS-$125
	
Section 1: Medical Information
• Do any of the following conditions relate to you?
YES 	NO 		
		Accutane or other similar medication 	
		Allergies 	
		Autoimmune disease, HIV, lupus, hepatitis 	
		Blood thinners — Heparin, Coumadin, Warfarin, etc. 	
		Breast feeding, pregnancy 	
		Cancer or post-cancer treatments 	
		Cardiovascular problems 	
		Cold sores or fever blisters without pre-medication 	
		Cortisone or steroid injections 	
		Cosmetic injections, fillers or implants, (i.e. Botox, collagen) 	
		Eczema, psoriasis 	
		Enlarged or painful glands 	
		Epilepsy 	
		Facial waxing services within 7-14 days 	
		Heart ailment 	
		Hypertension/high blood pressure 	
		Inflammatory conditions 	
		Irregular, pigmented moles, warts or growths, unidentified facial growth or mark 	
		Keloids, pigmented scars, icepick scars, new scar tissue 	
		Laser procedures, chemical peels, dermabrasion, microdermabrasion 	
		Light sensitive medication 	
		Loose, thin, aged skin 	
		Lymphatic disorder, inflammation of lymph vessels, lymphedema 	
		Medication: 	
		Pacemaker or metal implants 	
		Phlebitis, varicose veins 	
		Recent accident or serious injury 	
		Recent surgical or dental procedure 	
		Rosacea, telangiectasia/couperose 	
		Retin-A, Retinol 	
		Skin abrasions or lesions 	
		Stage Ill or IV acne 	
		Skin-lightening or bleaching agent 	
		Sunburn 	
		Thyroid conditions	
		Under medical care for an existing or suspected condition or disease 	
		Viral infection, influenza 	
		Other contraindication at discretion of skincare technician or medical practitioner: 	
• My interest in skincare treatment is primarily for (i.e. skin rejuvenation, acne, hyper-pigmentation, scarring, etc.) _______________________________________________________________________________________________________________________________________________________________________
• Specify your areas of concern (i.e. eyes, forehead, etc.) _______________________________________________________________________________________________________________________________________________________________________
SECTION 2: CLIENT CONSENT FORM
 (Initial each acknowledgement line below) 
1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months. _____(initial here) 
2. I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two days after any aggressive facial exfoliation treatment. ______(initial here) 
3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen. _____(initial here) 
4. 1 acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. _____(initial here) 
5. I acknowledge that if I fail to use a minimal sunscreen (SPF 15), I am more susceptible to sunburn, skin damage & hyperpigmentation. _____(initial here) 
6. I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. _____(initial here)
7. I acknowledge that I should avoid use of glycolic products for 2-4 weeks following the treatment. _____(initial here) 
8. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my □ medical or □ skincare professional during and following the treatment. _____(initial here) 
9. 1 acknowledge that I am not pregnant/lactating. _____(initial here) 
10. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. _____(initial here) 
11. I acknowledge that I  have answered all questions truthfully and completely _____ (initial here) 
12. I release Affordable Enhancements LLC and Affordable Cosmetics LLC, Veanessa Burbage and Dr. Patricia Brown any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products. _____(initial here) 
13. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. _____(initial here) 
Client Signature: ______________________________________ Date: ____________________ 
Skincare Practitioner Signature: __________________________ Date: ____________________