Hydrafacial Keravive Consent Form

Hydrafacial Keravive Consent Form

HydraFacial Keravive is a unique, relaxing treatment designed to cleanse, nourish, and hydrate the scalp for fuller and healthier−looking hair. As with most procedures, visible results from HydraFacial Keravive will vary from person to person.

• Your scalp may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on scalp sensitivity. In the event that these reactions occur, discontinue use of the take home spray until they are resolved.
• You may experience slight tingling and/or stinging in the treatment area. These sensations generally subside within a few hours.
• Do not use aggressive exfoliation, scrubs etc one week prior to treatment and one week post treatment.
• Client experiences may vary. Some clients may experience a delayed onset of symptoms.
• The scalp can be susceptible to sunburn/sun damage. Always avoid excessive sun exposure. We recommend using a minimum of SPF 30 sunscreen, protective clothing and accessories when exposed to the sun.

Do you have any of the following?

An autoimmune disease such as HIV, lupus, hepatitis, scleroderm(Required)
Scalp conditions such as eczema, dermatitis, or rashes(Required)
An active infection in the treatment area(Required)
Melanoma or lesions suspected of malignancy(Required)
Active sunburn(Required)
Pregnancy or lactation(Required)
Anticoagulants Therapy(Required)
Neurological disorders such as epilepsy(Required)
Infection in the urinary system including kidneys, bladder and urethra(Required)
Crohn’s Disease(Required)
Deep Venous Thrombosis(Required)
Active Acne/Inflammatory Acne(Required)

Have you recently?

Used Minoxidil (Rogaine) or similar topical medications or non−medical treatments(Required)
Color−treated your hair or added extensions(Required)
Used Propecia or any other medications or supplements(Required)
Received a PRP treatment or hair transplant(Required)

I acknowledge the following:

Photos may be taken before, during and after the HydraFacial Keravive 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 Keravive treatment by the staff at...
By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. This consent form Is valid for all future HydraFacial Keravive treatments. I will alert the staff If there are any future changes to my medical history.
Patient E-Signature(Required)
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