tenSkin Laser Intake 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 Diabetes Epilepsy 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 * Do you have any allergies? * No Yes Please specify (type of allergy) TENSKIN 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. PRE AND POST CARE * Checking the box next to each statement constitutes your initials, indicating your understanding and agreement to adhere to the pre and post care instructions provided. I understand that I will need to protect my skin in the area of treatment with a broad spectrum SPF 30+ pre and post IPLaser to reduce the possible risks of burns along with hyperpigmentation and hypopigmentation. I will not expose the treated area to the sun/tanning bed for two (2) weeks before and after my treatment. I will not expose the treated area to any invasive treatments for 4 weeks. I will avoid hot baths, saunas, steam rooms and strenuous exercise for a period of 24-48 hours after my treatment. CONSENT AND ACKNOWLEDGEMENT * By checking this box, I confirm that I am the client named on this form, and that I have read, fully understand, and agree to all the terms and conditions. Date MM DD YYYY Thank you!
