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FACIAL/HydraFacial CONSULTATION

Today's Date: April 18, 2021  

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

Parent or Guardian's Email Address

Email*

Confirm Email*
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

DATE OF SERVICE

1. What would you like to achieve from your treatment today?
2. Have you had a facial treatment before?*
No
Yes

If YES, when?
3. Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes

If YES, in the last month?
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

If YES, have you used in the last week?
5. Have you used an acne medication?*
No
Yes

If YES, when?
6. Are you lactating, pregnant or trying to become pregnant?*
No
Yes
7. Have you experienced Botox, Collagen Injections or Restylane in the last 14 days?*
No
Yes

If YES, please describe?
8. Have you ever had an allergic reaction to any of the following?
COSMETICS
MEDICINE
FOOD
ANIMALS
SUNSCREENS
IODINE
POLLEN
AHAS
FRAGRANCE
SHELLFISH
LATEX
DRUGS
ASPIRIN
OTHER

If YES, please describe?

9. What areas of concern do you have regarding your skin? Please check any that apply and explain.

SKIN
BREAKOUTS / ACTIVE ACNE
BLACKHEADS/WHITEHEADS
OILY SKIN
BROKEN CAPILLARIES
REDNESS/UNEVEN SKIN TONE
SUN SPOT/LIVER SPOT/BROWN SPOT
WRINKLES/FINE LINES
DULL/DRY/DEHYDRATED SKIN
FLAKY SKIN/ECZEMA/DERMATITIS
SUNBURN
ROSACEA
OTHER

If Other
EYES
DEHYDRATED
WRINKLES
PUFFINESS
DARK CIRCLES
OTHER

If Other
LIPS
DEHYDRATED
CRACKED/CHAPPED LIPS
COLD SORE
OTHER
10. Do you have any of the following?
LUPUS
VIRAL CONCERNS/HIV/HEPATITIS
MELANOMA OR UNIDENTIFIED SKIN LEISION
ANTICOAGULANT THERAPY
NEUROLOGICAL DISORDERS (EPILEPSY)
URINARY INFECTION/CROHNS DISEASE/HYPOTHYROIDISM
DVT/LYMPHEDEMA

Please advise below of any other medical conditions we should be aware of

If receiving a HydraFacial - please review the following information: 

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:

  • Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.   
  • You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.   
  • Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
  • You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
  • The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.   

I acknowledge the following:

  • I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre-and post-treatment.   
  • Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
  • The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Springs Eternal Spa.
  • This consent form is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.

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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