Hydrafacial Intake Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) Occupation Emergency Contact(Required) Emergency Contact Phone(Required)Emergency Contact Relationship What to ExpectYour 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. Guest 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.Section 1: MEDICAL INFORMATIONDo any of the following apply to you? 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) Lymphatic Disorder, inflammation of lymph vessels, lymphedema Deep Venous Thrombosis (Lymphatic drainage) Lymphedema (Lymphatic drainage) Recent dental procedure Rosacea, couperose Retin-A/Tretinoin/Tazorac/Retinol/Vitamin A derivatives Skin abrasions/lesions Sunburn/sun damage Swollen/infected tonsils Skin lightening/bleaching agent Thyroid conditions Type 1 Diabetes Under medical care for an existing or suspected condition or disease Have you recently? Used Accutane, topical medications or antibiotics Had aesthetic fillers, injectables or laser treatments Section 2: GUEST CONSENT FORMPlease check each one to agree(Required) 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 LaVida Massage. Consent(Required) I agree to the notice.DISCLAIMER: I have read the above information and I have addressed any concerns with my Esthetician. I give permission to my practitioner to perform the waxing procedure we have discussed and will hold them harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my Esthetician will take every precaution to minimize or eliminate negative reactions. I have read and understand the post-treatment home care instructions. I am willing to follow the recommendations made by my Esthetician for a home care regimen that can minimize or eliminate possible negative reactions. If I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold LaVida Massage or the Esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS CONSENT FORM, AND THAT THE INFORMATION I PROVIDED ABOVE IS COMPLETE, ACCURATE, AND UP TO DATE.Signature(Required)EmailThis field is for validation purposes and should be left unchanged.