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HydraFacial™ Treatment Consent Form

HydraFacial is the only hydra-dermabrasion 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.

Date: June 27, 2022

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Signature*
Second Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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 Client's Name

First Name*

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

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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.

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.
FOR MINORS ONLY:

Emergency Contact
How did you hear about us?
How did you hear about us?*
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*
Parent or Guardian's Information

Do you have any of the following?

Open lesion or cold sore*
No
Yes
An active infection in the treatment area*
No
Yes
Active sunburn*
No
Yes
Skin conditions such as eczema, dermatitis, or rashes*
No
Yes
An autoimmune disease such as lupus*
No
Yes
A viral concern such as HIV or hepatitis*
No
Yes
Anticoagulants Therapy*
No
Yes
Melanoma or lesions suspected of malignancy*
No
Yes
Active acne or infection*
No
Yes
Pregnancy or lactation*
No
Yes
Crohn's Disease (Lymphatic drainage)*
No
Yes
Hyperthyroidism (Lymphatic drainage)*
No
Yes
Deep Venous Thrombosis (Lymphatic drainage)*
No
Yes
Neurological disorders such as epilepsy (LED Lights)*
No
Yes
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)*
No
Yes
Lymphedema (Lymphatic drainage)*
No
Yes

Have you recently?
Saying yes does not preclude you from receiving treatments.

Used Accutane, topical medications or antibiotics*
No
Yes
Had aesthetic fillers, injectables or laser treatments*
No
Yes

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 Lux Tan and Cryotherapy.

  • By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. 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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