Perk Hydrafacial Consultation Form

Please read carefully, complete, sign and date this form prior to your treatment.

Name: *

Date: *

Address *

DOB: *

Email: *

Phone: *

Treatment:

Perk Treatment

Medical Information:

This section of medical conditions should not be treated either straight away OR until the condition resolves itself or not at all with Perk/HydraFacial

Do any of the following conditions relate to you? Please select the appropriate option.

Roaccutane or Accutane within the last 6 months *

Yes No

Allergy to shellfish *

Yes No

Any other allergies/intolerances; *

Yes No

Please specify

Autoimmune disorders (HIV, Lupus, Hepatitis etc.) *

Yes No

Pregnancy *

Yes No

Breastfeeding *

Yes No

Cancer or history of cancer; *

Yes No

Please specify

Cold sores within the last month *

Yes No

Cosmetic injections within the last 2 weeks *

Yes No

Any recent laser procedures in the treatment area? *

Yes No

Recent deep chemical peels in the treatment area *

Yes No

Facial waxing with last 2 weeks *

Yes No

Retin A or Retinol products *

Yes No

Active eczema on the treatment site *

Yes No

Open wounds on the treatment site *

Yes No

Fresh scars on the treatment site *

Yes No

Notes: Please specify here any other medical conditions we may need to be aware of.

I have answered and understood the above medical questionnaire to the best of my knowledge and all information provided is correct.

Client signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.