Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male
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1 SCULPSURE MEDICAL HISTORY FORM Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male Address: Family Doctor: Phone: Pharmacy: Phone: Emergency Contact: Phone: How did you hear about us? Which body area/areas or condition would you like treated? Please answer all of the following questions YES NO 1. Do you have ANY current or chronic medical illnesses? Disclose any history of heat urticaria, diabetes, autoimmune disorders or any im munosuppression, blood disorders, cancer, bacterial or viral infections, m edical conditions that significantly com promise the healing response, skin photosensitivity disorders, or any other condition or illness. Please List: 2. Do you have ANY current or chronic skin conditions? Also disclose any history of vitiligo, eczem a, m elasma, psoriasis, allergic derm atitis, any diseases affecting collagen including Ehlers-Danlos syndrom e, scleroderm a, skin cancer, or any other skin condition. Please List: 3. Are you currently under a doctor s care? If so, for what reason? 4. Do you take/use ANY medications (prescriptions and nonprescriptions), vitamins, herbal or natural supplements, on a regular or daily basis? Please List:
2 5. Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis? INFORMED CONSENT FORM The SculpSure delivers laser energy to heat the deep layer of fat. The heat that is created damages the fat cells. The damaged fat cells are then eliminated by the body through your lymphatic system. During the laser delivery the applicators cool the skin throughout the entire treatment. The cooling protects your skin while the energy heats your fat layer. When the treatment begins, it will feel warm, and over time the heat sensation will increase to short periods of intense deep heat. You may also experience some cramping, tingling, prickling or squeezing sensations deep in the fat layer. These sensations are normal and expected. These sensations indicate that the laser is effectively targeting and damaging the fat layer. The SculpSure is eye safe. There is no need to wear protective eyewear. Your skin may be slightly pink to red immediately after treatment. This may last for a few hours. Following the SculpSure treatment you may experience some swelling, tenderness, firmness or hardness at the treatment site. This usually resolves within 2 weeks but may last longer. The treated areas should be massaged two (2) times a day for five to ten (5-10) minutes. There are no lifestyle restrictions following your SculpSure treatment. It is recommended to increase your water intake after treatment. You may use ice packs or Tylenol according to package instructions to help ease tenderness. I have been thoroughly and completely advised regarding the end point of the procedure. I understand that the practice of medicine is not an exact science and no results have been guaranteed. I acknowledge that the results may not meet my expectations. I certify that no guarantees have been made by anyone regarding the procedure(s) that I have requested and authorized. There is no guarantee that the expected or anticipated results will be achieved. I have been informed that firmness, hardness, nodules, redness, tenderness, swelling, pain, and bruising, are the most common side effects. Other less common side effects which can occur are itching, skin contour irregularities, dimpling, hyperpigmentation/hypopigmentation, asymmetry, necrosis, changes in skin laxity, numbness, blister or burn. Yes No I confirm that I have not had sun exposure within the last 7 days. Yes No I consent to photographs and digital images being taken and used to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. No photographs or digital images revealing my identity will be used without my written consent. If my identity is not revealed, these photographs and digital images may be used, shared, and displayed publicly for such stated purposes without my permission. Yes No Before and after treatment instructions have been discussed with me. The procedure, potential benefits and risks, and alternative treatment options have been explained to my satisfaction. Yes No
3 I have read and understand all information presented to me before consenting to treatment. I have had all my questions answered. Consent for treatment of Client: Date
4 PRE-TREATMENT / POST-TREATMENT INSTRUCTIONS SculpSure Pre-treatment instructions: No sun exposure 7 days prior to the treatment. Remove all creams or oils prior to treatment. SculpSure Post-treatment instructions: May experience mild pinkness or redness, tenderness, swelling, pain, itching, and skin firmness. Tenderness may last up to two weeks and in some clients a bit longer. Use a cold compress and/or acetaminophen to help reliev e tenderness. Gently massage the area twice a day for 5-10 minutes. May resume normal daily activity including exercise immediately post treatment. Encourage proper hydration and light physical activity to help mobilize fat via the lymphatic system. Contact your physician if you have any concerns about your treatment areas such as increasing tenderness or swelling several days after your treatment, or if you develop blisters, hardened areas or nodules.
5 Treatment Record Client Name: Date: TX Area PAC #1 PAC #2 PAC #3 PAC #4 Notes: Posterior Anterior Lateral Clinician Signature: Date:
6 Scheduling Policy Due to the popularity of our services, we have found it necessary to implement the following policy regarding the scheduling of appointments. Once scheduled all appoint ments require a minimum of 24-hour notice for cancellation. Failure to follow this policy will result in the following: Missing 1 appointment without notice: $ Charge. Missing 2 appointments without notice: $ Charge. Missing 3 appointments without notice: $ Charge. No future appointments will be honored until the above fees are paid. Credit Card information will be collected in registration and will be used only for missing appointments. For Complimentary and Gift Certificate Appointments: Missing ANY complimentary appointment without a 24-hour notice will result in Complete Forfeiture of the appointment. Gift Certificates are subject to the same charges as regular appointments. I have read and fully understand this policy and agree to follow the terms within. Credit Card Info: Master Card Visa Card Holder Name: Card Number: Expiry Date: CVS # SIGNATURE: DATE:
513 West Maple Ave West, Vienna, VA
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513 Maple Ave West, Vienna, VA
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