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.

PRECAUTIONS:
• 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)

Yes

Scalp conditions such as eczema, dermatitis, or rashes(Required)

Yes

An active infection in the treatment area(Required)

Yes

Melanoma or lesions suspected of malignancy(Required)

Yes

Active sunburn(Required)

Yes

Pregnancy or lactation(Required)

Yes

Anticoagulants Therapy(Required)

Yes

Neurological disorders such as epilepsy(Required)

Yes

Infection in the urinary system including kidneys, bladder and urethra(Required)

Yes

Crohn’s Disease(Required)

Yes

Hyperthyroidism(Required)

Yes

Deep Venous Thrombosis(Required)

Yes

Lymphedema(Required)

Yes

Active Acne/Inflammatory Acne(Required)

Yes

Have you recently?

Used Minoxidil (Rogaine) or similar topical medications or non−medical treatments(Required)

Yes

Color−treated your hair or added extensions(Required)

Yes

Used Propecia or any other medications or supplements(Required)

Yes

Received a PRP treatment or hair transplant(Required)

Yes

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...

Name of treatment center:(Required)

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)

First Last

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Hydrafacial Keravive Consent Form