tenSkin Rx Laser Consent Form DATE OF CONSULTATION * MM DD YYYY PREVIOUS TREATMENTS * Have you had IPL, LASER, or electrolysis treatments in the past? YES NO HEALTH CONDITIONS * Do you have any of the following health conditions? (Please check all that apply) Cancer or Remission within 5 years Epilepsy Diabetes Pacemaker Solar Urticaria Lupus Keloid or Hypertrophic scars Low blood pressure High Blood Pressure Stroke Scleroderma Tuberculosis Hirsutism PCOS-Poly Cystic Ovarian Syndrome Pregnancy Hemophilia Vitiligo Pityriasis Versicolor Molluscum Contagiosum Sycosis Barbae Intertrigo Dermatitis HIV Hepatitis A, B, or C None of the above LOCAL CONTRAINDICATIONS IN THE AREA TO BE TREATED * (Please check all that apply) Hormone Imbalance Varicose Veins Macro Telangiectasia-Spider Veins Thrombosis Herpes Simplex 1 or 2 Thyroid Hormone Implants Breast Feeding Eczema Psoriasis Dermatitis Tattoos Metal Implants Lesions or moles Permanent Makeup Irritation or Local infections None of the above CURRENT MEDICAL CARE * Are you currently under a doctor’s care? YES NO Have you been prescribed Isotretinoin within the past year? * YES NO Are you currently using any topical prescription medications in the area to be treated? * YES NO In the past 6 weeks, have you exposed your skin to the sun, have been to a tanning booth or have applied a self-tanning lotion? * YES NO Have you had any cosmetic injections or procedures in the area to be treated within the past month * YES NO If Yes, please specify. Do you have any allergies? * YES NO If Yes, please specify. TENSKIN RX LASER CONSENT * Checking the box next to each statement constitutes your initials. I am aware of the contraindications to IPL & Laser and confirm that I have no health conditions that are contraindicated. I will notify my treatment provider of any changes to my health file prior to my next treatment. I understand that results are cumulative and gradual and that a series of treatments and specific intervals of sessions are recommended by the therapist. I authorize my service provider to take pictures before, during, and after the IPLaser360 treatments. I understand and agree to adhere to the pre- and post-care instructions provided to me by my laser therapist. I am aware of the possible temporary side-effects post IPL and/or laser. they can include Erythema , rash or irritation, redness, tinkling, and mild swelling for up to 72 hours. Marketing * I consent to the use of my photographs, videos, or images taken before, during, or after my treatment for marketing purposes, including but not limited to social media platforms, the clinic’s website, and promotional materials. I understand that my name will not be used unless I give explicit permission. Yes, I give my consent. No, I do not give my consent. Electronic Signature By filling in my first and last names below, I acknowledge that I have read and fully understand the INFORMATION ABOVE AND HEREBY CONSENT AND AGREE TO THE TREATMENT WITH ITS ASSOCIATED RISKS. First Name Last Name Email * Phone * (###) ### #### Thank you!
