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Facial Consent Form

The Hydration Facial treats a wide range of skin concerns, and is safe for virtually all skin types and tones. You can expect to leave your treatment feeling refreshed, with visibly glowing skin, cleansed pores, and smoother texture. It is great for combating clogged pores, dryness, redness, dullness, hyperpigmentation, acne, and leaves your skin clean and hydrated.

How It Works

STEP 1: Cleanse and Exfoliate- Your treatment begins with a skin analysis, cleanse, and steam.

STEP 2: Vacuum Extractions- A soothing “mini-vacuum” suctions out impurities, while a combination of salicylic and glycolic acids is applied to unclog dirt and debris from pores.

STEP 3: Hydration Infusion: Now that skin is thoroughly cleansed, peptides, antioxidants, and hyaluronic acid are infused to restore, rejuvenate, and detoxify.

Information to Know

A consent form package is designed to give information needed to make an informed choice of whether or not to do the Hydration Facial treatment. Although doing the Hydration Facial is effective for most clients, there is no guarantee regarding your (the clients) benefit or exact results from the procedure and NO refunds will be issued.

What to Expect After the Treatment

You may experience a temporary redness and tightness. This typically resolves within a few hours, but may take up to 72.

The Hydration Facial works to bring impurities to the surface and remove them — you may experience slight purging after. This is a good sign that the treatment is hard at work!

Your skin will be more sensitive to the sun after your treatment, so try to avoid direct sun exposure for at least 2 weeks after, and be mindful about applying SPF daily.

Results are immediate! By the end of your Hydration Facial, you can expect glowing skin, cleansed pores, and smoother tone & texture.

It is recommended to do one Hydration Facial per month for best results and overall skin health.

Hydration Facial Consent Form

No client may be treated without completing a consent form

    Please Check Each Box

    I hereby consent to the procedure. This constitutes to full disclosure and supersedes any previous verbal or written disclosures.

    (A) I understand that a skin test can determine whether I will experience a reaction to the products used by the specialist within 48 hours prior to treatment. However, I accept this will be inconclusive as to whether I will have an allergic reaction anytime in the future. I therefore waiver my option to an allergy test and wish to proceed with treatment.


    (B) I have undergone or been offered an allergy test prior to my initial treatment. I therefore release the Tech + Spa from liability to any allergic reactions I may experience associated with either the application of pre-treatment cream or any other products used after the procedure, immediately or at a later date.


    Required For Treatment: I consent to photographs being taken BEFORE, DURING, and AFTER my procedure. I agree to these being stored with my case file and will be used with the below written consent for promotional and social media purposes.

    Photo for Personal Records X Photo Consent for Madison Laser Spa Social Media X Print

    CLIENT BACKGROUND INFO/QUESTIONS

    Have you had any of the following in the last 30 days:

    Alpha Hydroxy Acid (AHA)

    Glycolic Products

    Roaccutane

    Gold Therapy

    Blood Thinning Medication

    Do you have any of the following skin conditions?

    Prone to Keloid Scarring

    Open wounds

    Severe Acne

    Psoriasis

    Vitiligo

    Lupus

    Pregnant or Breastfeeding

    Allergies or prior allergic reactions to medicine or products such as latex gloves, plaster

    Autoimmune disorders or immune-deficient

    Do you suffer from epilepsy

    Are you currently taking any medication?

    MUST list all medications here:

    Do you have or are you planning to have any injectable, fillers or chemical peels in the near future?

    Please list:

    Do you knowingly suffer from any infectious disease/current virus or sickness?

    Have high or low blood pressure

    Have diabetes

    Any respiratory or heart problems

    Do you smoke

    Prior Issues with scars – scar healing - keloid scarring

    Suffer from dizziness or fainting attacks

    Have Anxiety, depression, sleeping issues

    Have HIV/AIDS (had HIV/AIDS that is now undetected)

    Have Genital warts/ herpes / cold sores

    Have Hepatitis, HPV, and active STD

    Have Lymphatic problems

    Suffer from Haemophilia

    Have an allergy to penicillin

    Prior or known REACTION to Lidocaine

    Do you feel fit and well enough to have a Hydration Facial today with consent that your medical history has been fully disclosed such that any information you have not communicated to Madison Laser Spa, that could produce adverse harmful reactions, confirm Madison Laser Spa or any staff treating you shall not be held at the accountability? If you suffer from any of the above it is important that you notify Madison Laser Spa who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health.

    I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medical history it is my responsibility to inform my specialist.

    Contradictions: YOU CANNOT BE TREATED

    I agree with all points listed and discussed, and wish to proceed as recorded. I participated fully in the decision for Hydration Facial treatment. I hereby agree to follow all before and after care.

    By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

    Contact Us (646) 370-3308