MEDICAL PROFILE/INFORMED CONSENT FORM DIOLAZE/DIOLAZEXL HAIR REMOVAL

Personal Information

Client's Name (First):

Client's Name (Last):

Date of Birth:

I.D. Number:

Employment:

Address:

Email:

Work Address:

Home Telephone:

Cell Phone:

HEALTH QUESTIONNAIRE

Existing or recent illness details:

Hospitalization / surgery details:

Medication intolerance details:

Aesthetic procedures in the treatment details:

MEDICAL HISTORY

Please inform doctor/technician prior to treatment if you have any of the following conditions that may make you unsuitable for LASER Hair Removal treatments.

- Pregnancy or nursing
- Under 18 years of age (unless there is parents consent)
- Pacemaker or internal defibrillator or any electronic Implant such as glucose monitor
- Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical substance
- Current or history of cancer, especially skin cancer, or pre-malignant moles
- Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications
- Severe concurrent conditions such as cancer, cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidney diseases
- A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area (prophylactic treatment may be given)
- Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/freshly tanned skin
- History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry, cracked, ulcerated, infected and fragile skin
- Tattoos, permanent make-up, pigmented lesions (to be kept)
- Any medical condition that might impair skin healing
- Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction
- Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing
- Use of Isotretinoin (Accutane?) within 6 months prior to treatment.
- This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with DIOLAZE/DIOLAZEXL technology. If you have any questions before your treatment, please feel free to ask.