Hydro Facial Consultation Form
(Branch Reading)

First Name *

Last Name

Date of birth (DD-MM-YYYY) *

Gender *

Male

Female

Other

Phone *

Email *

Address

Street Address

City

State

Postal code

Client Evaluation

By completing this client profile, you will assist us in evaluating you and your specific concerns. The information you will provide will be used to determine what factors may affecting you as that we may recommend the proper care.

How often do you exercise? *

How many hours do you sleep per night? *

On a scale of 1 (low) to 10 (high) how would you rate your stress levels? *

Occupation? *

Age of children? (if any) *

Nutrition

Please indicates the frequency of these foods consumed on a weekly basis:

Sugar *

Spicy Foods *

Takeaways *

Salty food *

Snack foods *

Fast foods

Please indicates the quantities of fluid consumed on a daily basis.

Water *

Juices *

Tea *

Coffee *

Alcohol *

Fizzy Drinks *

Do you have any specific dietary requirements ? *

Health/ Medical

Doctor's name, address and phone number: *

If you select other kindly elaborate your health condition

Please list all medications that you have been prescribed by your GP: *

Please list any non- prescriptive medication: *

Heath/ Medical cont.

Please indicates the quantities of fluid consumed on a daily basis.

Retin-A

Accutane/Tetracyclene

Contraceptives/HRT

Dluretics

Antibiotics

Steroid Cream

Have you ever had any surgery or undergone plastic surgery?

If yes, When?

Where on your body?

What information can you provide about the procedure?

Have you undergone treatment from a dermatologist/ skin peels/ botox /dermal filler/ threads/ IPL or laser?

If yes, When?

What type of treatment?

What information can you provide about the procedure?

Home Skin care Regime

Describe in details (using product brand names ) exactly how you are presently caring for your skin

What are your concerns?

What is your specific concerns ?

Have you ever received hydro peel, radio frequency, Electro- ion therapy, or ultrasound on face or body previously ?

What were the results?

What are your expectations of your chosen treatment ?

Client Release

Relative Contra-indications
Pregnancy, Recent pregnancy or breast feeding
Heart Condition including pacemaker
Thrombosis or Thrombophlebitis
Anticoagulant Medication
History of cancer
Metal prosthesis or implants (area specific)
Diabetes
Epilepsy
Auto Immune Conditions
Skin Thinning Medication
Inflammation or infection in the treatment area
Ultrasound – possible side effects are
redness and skin sensitivity
Keloid scar tissue
Active acne, pustules and papules
Deep Cleanse/Exfoliation – possible side effects
are bruising, skin sensitivity and redness
Contagious or blood transmitted diseases
Skin thinning medication
Photosensitive medication
Haemophilia
Skin irritation or rash
Cryo/Heat Facial – possible side effects
are redness and heat reaction
History of Keloid scarring
Photosensitive medication
Skin thinning medication
Recent skin peeling
Active acne, pustules and papules
Radio Frequency – possible side effects are
skin sensitivity, redness, scabbing, blistering
History of Keloid scarring
Photosensitive medication
Skin thinning medication
Recent skin peeling
Active acne, pustules and papules
Hydro Peel – possible side effects are bruising, skin
sensitivity and redness
Contagious or blood transmitted diseases
Skin thinning medication
Photosensitive medication
Haemophilia
Skin irritation or rash
Electro Ion – possible side effects
are redness and tingling
Scarring or infection
Photosensitive medication
Fragile skin

I certify that the above statements are true and correct and I have been advised clinic completely understand the implications of the treatment that I will be receiving, including the listed side effects. At no time have I been misled or badly informed by the above mentioned therapist or company. Any falsifications of information submitted by myself could be detrimental to my health and success of my treatment, and the company will not be held liable. I hereby authorise and direct them to administer the prescribed process and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgement that:

(1) I have read, understood and fully agree to the foregoing and I have received and read the 3D-HydrO2 facial post care treatment information document.

(2) Give consent to the proposed treatment process that has been satisfactorily explained to me and I have all the information that I desire.

(3) I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any claims that I have or may have in the future in connection with the described treatment.

I give consent for my photos to be used for marketing/ advertising purposes *

Yes

Signature *

Clear

Our aim to provide incredible results in affordable prices.

Additional Comment