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Massage Cupping Informed Consent

Massage Cupping bodywork therapy is an adaptation of an ancient technique; the purpose of this technique is to promote health and healing by: loosening soft tissue and connective tissue, scarring and adhesions moving stagnation and increasing lymphatic flow and circulation. This therapy utilizes silicone or plastic cups and a vacuum pistol to create suction on the body surface. These cups are moved over the skin using gliding, shaking, popping and rotating techniques while gently pulling up on the cup, or may be parked for a short time to facilitate joint mobilization or soft tissue release. Suction reaches deep into the soft tissue, attachments and organs. Another benefit is to pull toxins and inflammation from the body to the surface of the skin where the lymphatic system can more readily eliminate them.

Potential reactions to Massage Cupping are temporary and may include:

  • Cup Kiss: discoloration due to toxins and old blood being brought to the surface
  • Post tenderness: usually less than experienced from deep tissue work
  • Redness and Itching: increased vaso-dilation and/or inflammation brought to the surface
  • Decreased Blood Pressure: due to vaso-dilation and/or nervous system sedation

Suggested after care recommendations:

  • Drink plenty of water, to help eliminate toxins out of the body.
  • Avoid showers, steam, sauna and exercise immediately following bodywork.
  • Light stretching and range of motion exercises are beneficial.
  • Exercise the next day will help increase circulation to aid in fading of cup kisses.

Contraindications:

People who are on blood thinners should not experience Massage Cupping. If you start taking such medication please inform the therapist so your treatment plan can be adjusted. If you are under the care of an acupuncturist, massage cupping could potentially interfere with acupuncture treatments, and should be avoided.

MANJAE COSMETICS has provided me with information on the Massage Cupping bodywork technique. If I choose to experience this therapy in my treatment, I understand the effects and after- care recommendations. It has been explained to me that there is the possibility of a temporary skin discoloration or “cup kiss”, appearing as tissue is released. I am aware that a “cup kiss” is NOT a bruise and that it will dissipate within a few hours to a few days.

I understand that all treatments by MANJAE COSMETICS are therapeutic in nature. I agree to notify MANJAE COSMETICS of any physical discomfort experienced during the session. I have stated all relevant physical conditions, and will inform MANJAE COSMETICS of any changes in my health.

I have read through and answered honestly all of the below questions. All previous questions of mine have been answered and I understand the treatment in its entirety.

 

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS

I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.

I understand that possible side effects of the treatment including: skin redness (erythema) and warmth. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.

I understand that not everyone is a candidate for this treatment and results may vary.

I confirm that I have read and understood the above information and will undergo the treatment out of my own free will.

I believe I have adequate knowledge upon which to base an informed consent.

Financial: I understand that all payments are due at time of service. To receive package prices, payment must be made for the entire package prior to service. Money for prepaid packages is non-refundable, however, credit for services yet-to-be delivered may be applied to receiving any other services or products offered at MANJAE COSMETICS (credits are calculated on non-package pricing).

Cancellation of appointments without rescheduling must be done 48 hours prior the appointment to avoid treatment fee charges.

I affirm that all information provided below is correct to the best of my knowledge.

 

Precautionary Corona Virus Liability Release Form

Due to the 2019-2020 outbreak of the novel corona virus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.

Symptoms of COVID-19 includes:

  • Fever
  • Fatigue
  • Dry Cough
  • Sore Throat
  • Muscle Pain
  • Headache
  • Chills
  • Difficulty Breathing
  • New loss of Taste or Smell

I, Agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. 


I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days. 


I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. 


I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.


I understand that this business (D’Lux Artistry) and my PMU artist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

By signing below, I agree to each above statement and release the PMU artist and business from all liability for the unintentional exposure or harm due to COVID- 19.

Your PMU artist and all employees if this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to fight the spread of COVID-19 and other communicable conditions more thoroughly.

Today's Date: April 1, 2023 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency contact

Emergency contact name *

Emergency contact phone *

Relationship to you
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

ULTRASOUND CAVITATION CONSENT FORM 

ULTRASOUND CAVITATION TREATMENT AREA: (Please check all that apply)
Abdomen
Waist
Neck
Arms
Inner/ Outer Thighs
Lower Back
Upper Back
Hips
Buttocks
Calves
MEDICAL BACKROUND: (Check if you answer YES to any of these)
Are you pregnant or nursing?
Do you have any kind cancer?
Acute inflammation?
Are you epileptic?
Do you have any cardiac or vascular problems?
Do you have a wound that has not healed?
Current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Abnormaly high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?

If you checked any of the above questions, please explain here

Current medications that you are taking

Are you taking any recreation drugs?

INFORMED CONSENT FORM FOR MULTIPOLAR RADIOFREQUENCY TREATMENTS 


Occupation *
Medical history
Pregnancy or nursing (current only).
Heavy menses/bleeding.
Dental implants, braces, caps, metal fillings (amalgams, gold) - for facials, please circle all that apply.
Botox or filler in treatment area.
Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device.
Metal implants or other implants in the treatment area- ie. IUD, screws, plates.
Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area.
Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of Immune suppressive medications.
Active weeping acne.
Continuous use of Retin A, retinol.
Herpes (active).
Medications such as blood thinners.
Skin blotches or rosacea.
Severe concurrent conditions such as cardiac disorders or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin.
Chemical sensitivities such as reactions to cosmetic products or perfumes.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.

If Chemical sensitivities was checked; If known, please list specific offending ingredients
Disqualifying Conditions for Multipolar Radio Frequency Treatments - Check off what applies to your condition
Implants: heart pace-maker, braces, cochlear, or any other artificial organ inside the body
Pregnancy
Lactation
Tuberculosis
Not feeling thermal changes
A burn or care after such a burn
Active cancer
Severe active arthritis
Active gout
Severe cardiovascular disease, circulation troubles (thrombus arterial sclerosis, etc.)
Coagulation disorder or bleeding tendency
Acute hernia, discopathy, spondyloslysis
Migraines and Epilepsy
Malignant Tumors
Acute infections or inflammations
Acutane and retinol
Botox or filler in treatment area
Suppuration of soft tissues
Kidney stones
Any active condition in the treatment area, such as Herpes, sores, psoriasis, dermatitis, eczema and rash

Client Health History: Body Contouring, Cellulite Reduction, and/or Skin Tightening Health History Intake 

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): *
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?*
No
Yes
Areas of concern. Check all that apply: *
Abdomen
Upper Legs "Saddle Bags"
Lower Legs (Hamstring Area)
Inner Thigh
Arms (tricep side)
Back
Buttocks
Calf
Flanks "Love Handles"
Other

Cosmetic History 

Have you used Accutane in the past year?*
No
Yes

Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmenta- tion? Please List;

Health History 

Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Do you exercise?*
No
Yes

How often?

What type?
Have you had any other cosmetic surgeries/procedures?*
No
Yes

If yes, when?

What body area(s)?
Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have moles/skin growths in the area to be treated?*
No
Yes

Do you have any allergies to medications, food, latex, topical products, and/or other substances?
Do you have any of the following conditions?
Epilepsy
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Dental implants, crowns, metal fillings
Pacemaker or internal defibrillator, implanted neuro stimulators, or other internal electric device
Metal implants or other implants in the treatment area, i.e. IUD, screws, plates
Varicose veins
History of skin disorders
Do you have a history of Erythema Ab Igne (EAI), which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*
No
Yes
Do you have any other health condition not mentioned here?*
No
Yes

If yes, please list
Have you undergone any recent surgery?*
No
Yes

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly *

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly *

Is there anything else you would like us to know?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this his- tory. A current medical history is essential to execute appropriate treatment procedures. *
I agree
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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