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Date of last hydrafacial
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Type of Hydrafacial
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Booster
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SPF applied after procedure?
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Additional Treatment Notes
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Post Care Instructions
• • •
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Provider completing treatment
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Conversation Notes
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Medical History
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Allergy shellfish (in Activ-4)
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Accutane in past 6 months?
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Allergy aspirin or sulfur (contraindication)
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Any skin disorders (eczema, psoriasis, keloids)
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Retinoid Use past 2 days
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Photosensitizing medication?
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history of autoimmune disease?
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On anticoagulants?
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Any chronic medical conditions?
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If + chronic medical conditions, please describe
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Botox within past 7 or filler within the past 10 days?
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Any microdermabrasion , laser procedures, or chemical peels within the past 4 weeks?
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Risks/Benefits Reviewed and questions answered
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