Hydrafacial MD Service Protocol Manual

Client Consultation and Release Form

Welcome to Nancy Taylor Day Spa
We are committed to providing you with unparalleled services and products. Please complete the following form as thoroughly as possible to help us achieve this goal.
Thank you for choosing Nancy Taylor Day Spa. It is our pleasure to serve you

First and Last Name: * Please enter your name.

Date of Birth: *

Please enter valid date.

Email: * Please enter your email.

Phone number: * Please enter your phone number.

Please fill in Address: *

Please enter address.

Services to be performed

Hydrafacial MD

Red Light Therapy

Lymphatic/Massage Therapy

Blue Light Therapy

Please select at least one choice above.

Do you have any of the following allergies? *

Shellfish

Asprin

Methylisothiazolinone

None of the above

Please select at least one choice above.

Please list any other allergies: Please enter your answer here.

If you checked box to any of the above conditions, please explain: Please enter your answer here.

Please list all medications you are currently taking: Please enter your answer here.

My interest in skincare procedure is primarily for (i.e. skin rejuvenation, acne, hyperpigmentation, scarring, etc.) Please enter your answer here.

Specify your areas of concern (i.e. eyes, forehead, etc.) Please enter your answer here.

CLIENT CONSENT FORM: Initial each acknowledgement line below

Initial Here

I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two days after any aggressive facial exfoliation treatment. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or face. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. * Please click the yellow area and provide your initials here.

Initial Here

I have disclosed my history of allergies above. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience allergic reactions. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that if I fail to use a minimal sunscreen (SPF 30), I am more susceptible to sunburn, skin damage and hyperpigmentation. I should avoid excessive sun exposure, especially between 10 a.m. and 2 p.m. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following the treatment. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician and/or skincare practitioner during and following the treatment. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that I am not pregnant/lactating. * Please click the yellow area and provide your initials here.

Initial Here

I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. * Please click the yellow area and provide your initials here.

Initial Here

I acknowledge that I have answered all questions truthfully and completely. * Please click the yellow area and provide your initials here.

Initial Here

I release Edge Systems, the Aesthetician, management and staff of Nancy Taylor Day Spa and Aveda Hair Salon from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products. * Please click the yellow area and provide your initials here.

Initial Here

I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name will not be used to identify these photographs without my written approval. * Please click the yellow area and provide your initials here.

By signing below, I certify that I have read and fully understood the contents of this consent form, and that the information I provided above are complete, accurate, and up-to-date to my knowledge.

Your signature *

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Your Name * Please enter your answer here.

Signature Date *

Please enter valid date.

Digital waivers for spas have a legitimate position in spa service.

Hydrafacial MD Service Protocol Manual

​Client Consultation and Release Form

Client Consultation and Release Form