Hydrodermabrasion Form

First name:*

Surname:*

Contact Number:*

Address:*

Postcode:*

Doctor's Name:*

Surgery Name and Address:*

I am aware that the Beauty Barn may wish to contact me for follow up appointments, details of other treatments, or for marketing purposes and I consent to my contact details being used for these purposes. I also agree with prior consent for any before and after pictures to be used*.

I allow the website to collect and store the data I submit through this form*

Medical History

Do you have any current or chronic medical illnesses we should know about? E.g. Haemophilia, cancer, epilepsy, diabetes, cardiac abnormalities, platelet abnormalities, scleroderma, collagen vascular diseases).*

Please list:

Do you take any medications, herbal supplements or topical on a regular basis? E.g. Antibiotics, Hormones, Retin-A, Glycolic Lactic Acid etc. Or have you taken Accutane or anticoagulants, steroid therapy.*

Please list:

Have you had/have cold sores?*

Do you have or been exposed to HIV (AIDS)?*

Are you immunosuppressive?*

Do you have a bacterial or fungal infection in the area to be treated?*

Are you or could you be pregnant?*

Hypersensitivity and Fragility

Do you have any allergies to medications, foods, latex, nickel, vitamin c, hydrochloric retinol, collagen or any other substances? (please ask if unsure to see the natural ingredient list of your serum being used today)*

Are you sensitive to skincare products?*

If Yes, please list:

Sun History and Skin

Any sun exposure, used tanning creams or tanning beds in the last 4-6 weeks?*

When exposed to the sun, do you:*

Do you have any moles, skin tags or lesions?*

Have you ever had botox or fillers?*

If yes, please state when you last had it done:

Ability to Heal

Do you form thick or raised scars (Keloid scarring)?*

Do you use wax or use depilatories?*

Does your skin appear fragile?*

Do you bruise easily?*

Do you bleed easily?*

Skin Type

Does your skin ever flake or feel tight and dry?*

Is your skin shiny a few hours after cleansing?*

How often do you experience blackheads or blemishes?*

How noticeable are your pores?*

Do you blush easily?*

Do you have any history of acne or periodic breakouts?*

Do you have any areas of concern with acne scarring?*

If yes, please list:

I understand that failure to disclose information requested above may result in adverse side effects unknown, because of this treatment and to which I take liability and confirm that my medical history is accurate and complete to my knowledge. I accept that any treatment I have taken is at my own risk. I understand that withholding any medical information may be detrimental to my health and safety during the procedure which the practitioner agrees. Therefore, if there are any adverse effects due to an undisclosed medical condition, the Beauty Barn is absolved. It is my responsibility to advise my practitioner if there is any change. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.*

Yes

The treatment has been fully explained to me. I understand that this treatment may take several sessions and a course of treatments is recommended for best results.*

Yes

I agree to follow all the aftercare advice as provided by my therapist.*

Yes

I understand that there is a risk of some side effects including but not limited to, reddening, bruising, tenderness. I accept these risks are possible and do not hold the therapist or the company responsible for any adverse reactions that may occur from treatment.*

Yes

I have asked all relevant questions pertaining to the treatment and am satisfied with the explanation and information given to me regarding the possible side effects and outcome of the treatment.*

Yes

I have been given full pre and post treatment advice and understand and agree to follow these guidelines at all times during the treatment programme.*

Yes

In the unlikely event of an adverse reaction, I will advise the salon within 24 hrs and in the case of any serious side effects, will contact my GP to obtain medical advise.*

Yes

I confirm that I am over the age of 18 years.*

Yes

I confirm that I have read and agree to all the guidelines and have had a patch test of the serum and the outcome did not produce any sensitivity.*

Yes

I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.*

Yes

Signed:

Date:*

SUBMIT

Beauty Barn Turvey

Medical History

Hypersensitivity and Fragility

Sun History and Skin

Ability to Heal

Skin Type

Thank you!

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