Lavender Falls Face & Body Spa LLC

Client Informed Consent Form

HydraFacial  / Custom Facial




19239 Stone Oak Pkwy #201

San Antonio, Texas 78258

Phone: 210-446-0903


Online Booking Available

Treatment Consists of:

HydraFacial MD – Liquid dermabrasion, light foam peel, hyaluronic acid and serum infusion.

Custom Facial – May include deep cleansing, exfoliation, extraction, enzyme, mask application, hydration/serum infusion.

Custom Facials / HydraFacial MD Treatments remove dead skin cells and extract impurities while simultaneously providing the new skin with cleansing, hydrating and moisturizing serums. The goal of these treatments is to deep cleanse and hydrate facial skin with improvement in skin tone and texture, acne breakouts and general skin health.

Clients Acknowledgements:

Hydration Facials and Facial treatments are not recommended if you are pregnant or breastfeeding, if you have an active infection at the site, if you have an unwillingness to wear SPF products or a history of light sensitive seizures. Allergy to aspirin is a contraindication for the Beta-hd serum only. If you have an aspirin allergy, please inform your aesthetician prior to treatment.

Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

     Accutane with the last year  

     Allergies - I am not allergic to any of the ingredients in the prescribed treatment.

     Sunburn or Sun Exposure- 1 week prior to treatment.

     Recent Laser Treatments or Chemical Peels

     Electrolysis, Waxing , Depilatory Creams , Laser Hair Removal – 1 week prior to treatment

     No prescriptive topicals, abrasive scrubs or strong exfoliants – 1 week prior to and post treatment.

(Retin-A, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol, glycolic acid, salicylic acid).

      Pregnant or Breastfeeding


Cosmetic Injections:

      Botox/Dysport/Xeomin within the last week.

      Dermal Fillers within the last two weeks.

*Notify your aesthetician of any medical conditions & medications (Current & within the last 90 days).

Post Treatment Acknowledgement

      No prolonged sun exposure 1 week post treatment.

      Sun protection of at least broad spectrum SPF 30 is recommended.


      You may return to their normal activities immediately after the treatment and may apply makeup right away if desired, unless otherwise directed by your aesthetician.



*Our Facials are adjusted to meet the needs of the client and may still be provided upon evaluation and discretion of the aesthetician.

Side Effects:

Possible side effects include but are not limited to:

• Common side effects such as slight redness usually subside within a few hours after treatment.

• Uncommon side effects such as bruising, skin irritation and exacerbation of skin breakout can occur.

• Rarely, allergic reaction, pigment changes of freckles, moles or skin such as hypopigmentation (lightening) or hyperpigmentation (darkening) can occur and may resolve, but can be permanent. Scarring and textural changes are also rare side effects but can result from this procedure. There may be risks not yet known at this time.


    I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

    The Hydration Facial or Facial treatment has been fully explained and any questions or concerns that I have, have been addressed.

    I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

    I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

     Photographs May be taken for comparison for future treatments for my chart.


I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.


I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.


All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.





Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face & Body Spa LLC for your aesthetic needs

Feel free to contact us at 210-446-0903 if you have any questions



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Signature Certificate
Document name: Facial
lock iconUnique Document ID: 005dd7f35cfd7bc89e98acfe630a517571bf3f09
Timestamp Audit
April 8, 2017 6:58 pm CSTFacial Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP