TenSkin Contour 360º RF Consent Form DATE OF CONSULTATION * MM DD YYYY CLIENT INFORMATION First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY 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) Active acne Active Bacterial, Fungal or Viral Infection Taking Blood Thinners Cardiac Disease or Abnormalities Recent Chemotherapy or Radiation Skin Cancer Vascular Disorders i.e. Rosacea, Telangiectasia or Erythema Vascular Lesions i.e. Angiomas Collagen Disorders i.e. Scleroderma Compromised Healing Eczema, Psoriasis or Dermatitis Hemophilia or Bleeding Disorders Hormone Replacement Therapy Keloid or Hypertrophic Scaring Pregnancy or Breast Feeding Raised skin lesions i.e. moles Recent chemical peel, laser or IPL treatments Recent use of topical and oral medications i.e. Isotretinoin, Retinoids. Sunburn Tattoos Metal Implants in the Treatment Area Clients receiving cosmetic injections can be treated after a minimum time gap (to be checked with the Distributor) Clients with a history of diseases stimulated by heat History of Skin Disorders (unless approved by a Dermatologist) None of the above LOCAL CONTRAINDICATIONS IN THE AREA TO BE TREATED * (Please check all that apply) Clients with the following conditions should not be treated with the Contour 360°, if so, suitable alternatives will be discussed. 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 the care of a physician or dermatologist? YES NO Have you been prescribed Isotretinoin within the past year? * YES NO Are you currently using any products containing Retinoids, Glycolic Acid, Lactic Acid, Alpha Hydroxy Acid (A.H.A.) or Benzoyl Peroxide? * 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 COUNTOUR 360º RF CONSENT * Radio Frequency is a non-invasive skin treatment to help smooth fine lines, tighten and contour the face and neck and to help reduce the appearance of cellulite. Radio Frequency uses electrical pulses to target and penetrate the deeper layers of skin using heat to stimulate collagen. During the treatment you will feel a brief deep heating sensation. It is a non-invasive treatment and requires no down time. Checking the box next to each statement constitutes your initials. I have completed the Health Evaluation form and do not have any contra-indications to Radio Frequency. Treatment areas include: Face, Neck, Arms, Back, Stomach, Buttocks and Legs. Side effects can include swelling, redness, bumps, minor burns on or around the treated area. Results should be visible immediately and will improve over a period of two to six months. I am aware that a series of 6-10 treatments will be needed and are scheduled 1 or 2 weeks apart. I am aware that in order to maintain my results, quarterly follow up treatments are recommended. I will notify my service provider of any changes to my health form or if prescribed new medications. I will follow the skin care recommendations provided. Alternative methods to Radio Frequency are Botulism Toxin injections (i.e. Botox, Disport), Dermal Fillers, Laser, IPL and Surgery. _ I am aware the results vary and are highly dependent on age. Please note that 3% of clients do not respond well to Radio Frequency. ACKNOWLEDGMENT: * My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release Contour 360, staff, and technicians from liability associated with the procedure. YES NO Filling in the client's name below constitutes their signature: * Please insert first and last names. Thank you!
