tenSkin Rx Laser Consent Form DATE OF CONSULTATION * MM DD YYYY CLIENT INFORMATION First Name Last Name Email * Phone * (###) ### #### 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. Thank you!
