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HYDRAFACIAL TREATMENT CONSENT FORM

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. The 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 (initial):

I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids, retinol that are not part of the recommended take-home regimen in the treated areas for a minimum of 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 Restorative Skincare, LLC.

  • 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 that staff if there are any future changes to my medical history.   

Date: February 22, 2026

First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Do you have any of the following?
Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Melanoma or lesions suspected of malignancy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system I.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn's Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphadema (Lymphatic drainage)
Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injections or laser treatments
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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