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COSMED LASER SPA 

HYDRAFACIAL MD 

SECTION 1: MEDICAL INFORMATION  

Absolute Contraindications :

Accutane or other similar medication 
Autoimmune disease, HIV, lupus, hepatitis, scleroderma 
Active infection in the treatment area 
Melanoma or lesions suspected of malignancy 
Active Sunburn 
Pregnancy (medical-legal) 
Breastfeeding (medical-legal, may increase skin sensitivity & likelihood of PIH Epilepsy contraindicated for LED light therapy  

 

SECTION 2: CLIENT CONSENT FORM  

(initial each acknowledgment line below)  

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

 

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 10am-2pm. 

 

I have disclosed my history of allergies above and I acknowledge that I may experience an allergic reaction.

 

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

 

I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre- and post-treatment. 

 

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

 

I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician and /or skincare practitioner per and post the treatment.

  

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

I also understand that any appointment that I make that is not cancelled within 48 hours I will be charged a ($50 or forfeiture of one of the treatment) no show fee

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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