Vibrant Skin Consent

Vibrant Skin Rejuvenation, LLC

HydraFacial Treatment Informed Consent

Client information

Client name *

Date of birth

Treatment date *

Phone

Before and after photos

before treatment

Take before photo

after treatment

Take after photo

Photos are optional and are stored with this visit after you tap Save record.

Treatment description

A HydraFacial is a non-invasive skin-resurfacing procedure that may include cleansing, exfoliation, extraction, hydration, topical serums, and optional LED light therapy. Products, boosters, and settings may be adjusted based on skin condition, goals, history, and provider judgment. Results vary and no specific outcome is guaranteed.

Health and skin disclosure

Please select every item that applies.

Allergies

Medications / topical products

Relevant medical or skin conditions

LED light therapy - epilepsy and photosensitivity

Bright, flashing, or pulsing light may trigger seizures in people with photosensitive epilepsy or certain seizure disorders. Clients with epilepsy, seizure history, or known photosensitivity will not receive LED therapy unless appropriate under qualified clinical guidance and device instructions. LED therapy is optional.

No known history of epilepsy, seizures, or photosensitive reactions.I have or have had epilepsy, seizures, or photosensitivity and informed my provider.I decline LED light therapy.

Possible risks and aftercare

Temporary or unexpected reactions may include redness, irritation, sensitivity, dryness, tightness, itching, swelling, tenderness, peeling, breakouts, bruising, or pigmentation changes. Allergic reaction, infection, or prolonged irritation may occur. I will report unusual discomfort and follow instructions regarding sun exposure, skincare, exfoliation, retinoids, acids, and other treatments.

Photography consent - optional

Treatment record only - photographs may be taken for treatment documentation.Marketing authorized - de-identified before-and-after photographs may be used for education, website, social media, or promotional materials.I do not authorize photographs.

Client acknowledgment

I provided accurate information, had an opportunity to ask questions, understand the treatment, benefits, limitations, alternatives, and risks, and may decline or stop treatment. I voluntarily consent to treatment by Vibrant Skin Rejuvenation, LLC and will report relevant changes before future treatments.

I have read and agree to this acknowledgment. *

Client signature

Treatment record

Treatment menu

Nail service treatment plan

Add-ons

Botox / neurotoxin menu

Client total

$0.00

Treatment, selected add-ons, and neurotoxin charge. Saved with this client record.

Provider name

Billing summary

No treatment selected · $0.00

Products / boosters

Areas treated

Inventory used during this treatment

Check each supply used and enter the quantity. Stock will update when this consent is saved.

No inventory items have been added yet.

Provider notes

HydraFacial consent