Reemake Skin Care Medical Spa & Laser Clinic
Name Age Have you ever had the following? Current or history of cancer, especially malignant melanoma or recurrent non-melanoma skin cancer, or pre-cancerous lesions such as multiple dysplastic nevi.Any active infection.Diseases which may be stimulated by light at 515 nm to 1200 nm, such as history of recurrent Herpes Simplex.Systemic Lupus Erythematosus, or Porphyria.Use of photosensitive medication and/or herbs that may cause sensitivity to 515 - 1200 nm light exposure, such as Isotretinoin, tetracycline, or St. John's Wort.Immunosuppressive diseases, including AIDS and HIV infection, or use of immunosuppressive medications.Patient history of hormonal or endocrine disorders, such as polycystic ovary syndrome or diabetes, unless under control.History of bleeding coagulopathies, or use of anticoagulants.History of keloid scarring.Very dry skin.Exposure to sun or artificial tanning during the 3–4 weeks prior to treatment. Are you pregnant? YesNo What medications are you taking (including aspirin)? Daily consumption of alcohol: Allergies: Are you taking any herbal preparations? (St. John’s Wort, etc.) Do you wear contact lenses? YesNo Skin type (when exposed to the sun without protection for about 1 hour)aways burns, never tansalways burns, sometimes tanssometimes burns, sometimes tansalways tansHispanic, Asian, Mediterranean, Middle EasternBlack When were you last exposed to the sun (including tanning booth)? Do you use chemical sun tanning lotions? Are you planning a holiday in the sun? Reason for visit (area to be treated) Prior treatment (if any)
Patient name Treatment sites I duly authorize the staff at Reemake Studio to perform the Laser Hair Removal procedure and any other measures which in their opinion, may be necessary.
I understand that the diode laser is a device used for laser hair removal and that clinical results may vary in different skin types and hair types. I understand there is a possibility of short-term effects such as reddening, blistering, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me. (patient’s initials)
Clinical results may vary depending on individual factors, including medical history, skin and hair type, patient compliance with pre/post treatment instructions, and individual response to treatment. I understand that epilation with the diode laser system is a safe alternative to methods used for removing unwanted hair, such as shaving, waxing, chemical epilation and electrolysis. I understand that treatment by the diode laser hair removal system involves a series of treatments and the fee structure has been fully explained to me (patient’s initials)
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I am not pregnant at this time, and that I have not taken Accutane within the last 6 months. I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.
Patient Signature Date:
