About this template
A Hydrafacial Treatment Consent Form is essential for medical spas, dermatology clinics, and aesthetic practices to safely onboard clients. Before proceeding with skin rejuvenation treatments, practitioners must screen for contraindications such as active infections, recent laser treatments, specific medications, and skin conditions to ensure patient safety and minimize risk.
This template streamlines the intake process by gathering comprehensive medical history, emergency contacts, and explicit treatment authorization in one organized digital form. Clients can easily review potential risks and share crucial health disclosures directly from their phone or computer before arriving for their appointment.
Doc2Form allows you to instantly transform this comprehensive consent workflow into a ready-to-use Google Form. Keep your client records organized in Google Drive and streamline your pre-treatment protocol without dealing with clunky paper clipboards.
Key features
- Collect complete medical history and contraindication disclosures
- Gather emergency contact details and basic patient demographics
- Document client acknowledgment of treatment risks and aftercare
- Access responses securely through Google Drive and Sheets
- Send easily to clients via email or text before their appointment
Use cases
- Medical spas onboarding new clients for signature facial treatments
- Dermatology clinics screening patients for aesthetic procedures
- Day spas collecting liability waivers and health questionnaires
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Enter your date of birth (MM/DD/YYYY).
- Email Address (Short answer)Where we can send your appointment confirmation and aftercare instructions.
- Phone Number (Short answer)Your primary contact number.
- Street Address (Short answer)House number, street name, and apartment/suite.
- City, State, and Zip Code (Short answer)Enter your city, state, and postal code.
- Emergency Contact Name (Short answer)Name of someone we can reach in case of an emergency.
- Emergency Contact Phone Number (Short answer)Phone number for your emergency contact.
- Are you currently experiencing active acne, infection, open lesions, cold sores, or sunburn in the treatment area? (Multiple choice)Select yes if any of these skin conditions are currently present.
- Do you have a history of eczema, dermatitis, rosacea, or lupus? (Multiple choice)Select yes if you manage any of these chronic skin or autoimmune conditions.
- Are you currently pregnant or lactating? (Multiple choice)Certain serums may need to be adjusted during pregnancy or breastfeeding.
- Are you currently taking blood thinners or have a bleeding disorder? (Multiple choice)This helps us avoid bruising during extractions.
- Have you used Accutane, strong retinoids, or topical antibiotics in the last 6 months? (Multiple choice)Recent use of strong exfoliants can increase skin sensitivity.
- Do you have any known allergies to aspirin, shellfish, or skincare ingredients? (Multiple choice)Hydrafacial serums may contain botanical extracts or salicylic acid derived from aspirin.
- List any allergies, current medications, or recent aesthetic procedures (Paragraph)Please provide details if you answered yes to any of the health questions above, or list any current medications.
- Treatment Consent Confirmation (Multiple choice)I confirm that the information provided above is accurate to the best of my knowledge. I understand the potential risks and benefits of the Hydrafacial treatment and give my informed consent to proceed.
- Electronic Signature (Short answer)Please type your full legal name to serve as your electronic signature.
FAQ
Why is a consent form required for a Hydrafacial?
Even though a Hydrafacial is non-invasive, practitioners must check for skin conditions, active rashes, recent Accutane use, or allergies that could interact unfavorably with active treatment serums.
Can I customize the medical history questions?
Yes! Once generated in Google Forms, you can easily add, remove, or edit any questions to match your specific clinic protocols.
How do clients sign the form?
Clients can fill out and submit the Google Form online before arriving. You can also include an acknowledgment checkbox confirming they have read and agreed to the treatment terms.
Where are the patient responses stored?
All submissions are saved directly to a connected Google Sheet in your Google Drive, making it easy to review responses before the appointment.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.