Perk Hydrafacial Consent Form (Face to face) | Webform Portal

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Perk Hydrafacial Consent Form

Client Name: *

Date: *

Therapist Name: *

I give permission for the therapist named above to carry out the Perk Hydrafacial treatment on myself and have read and understood the information about the treatment and the risks associated.

(please initial) *

1. I acknowledge that I am not pregnant or breast feeding, haven’t used Roaccatune within the last 6 months, haven’t received any cosmetic injections with the last 2 weeks, I don’t suffer from cancer and autoimmune disorders and do not have any known allergies to shellfish. I have specified any other allergies I have in the medical questionnaire form.
2. I have been given a full consultation and explanation of the Perk/HydraFacial treatment and all my questions are answered.
3. I acknowledge that there is no guarantee to the results of the treatments and acknowledge the need for the continual care for the extension of treatment results.
4. I acknowledge that it is my responsibility to use a minimum of SPF 30 following my treatment.
5. I understand that there may be skin reactions to the ingredients or the treatment itself, and skin may experience temporary irritation, tightness, redness, itchiness and swelling. All of these affects will resolve themselves within days to weeks depending on the skin sensitivity.
6. I understand that it is my responsibility to avoid Retinol, Retin-A products pre and post Perk/HydraFacial treatments for a minimum of 2 days.
7. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions.

8. I consent to the use of my before, during and after facial procedure photos for education and promotional purposes *

Yes No

9. From time to time we would like to contact you with marketing messages, special offers and other information. If you are happy to receive this information tick this box.

Yes

Client Signature: *

Tap or click on the signature above to sign

Practitioner 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.

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Comments:

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Covid-19 Guidance

Appointment Guidance

- Please only attend at your appointment time

- Please ensure you are on time - if you are late this may result in your appointment being cancelled

- Please attend your appointment unaccompanied

- Please limit the personal possessions you bring with you

- Hand sanitiser will be provided upon arrival and will be available throughout your appointment

- Please wear a face covering to enter and walk around the salon/clinic

- We encourage contactless/card payments where possible

- If you experience Covid-19 symptoms after your appointment please contact us immediately

Have you, or anyone in your household, had any of the following symptoms in the last 14 days: dry cough, fever, high temperature, shortness of breath, loss of sense of taste or smell, sore throat? *

Please DO NOT attend your appointment. Please contact us to cancel / reschedule.

Have you, or anyone in your household, been in contact with any confirmed COVID-19 positive patients? *

Please DO NOT attend your appointment. Please contact us to cancel / reschedule.

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