Intake Formulier Laserontharen EN

Intake Formulier Laserontharen EN

Name:
Date of Birth:
Streetname & Housenumber:
Postal code:
Residence:

Phonenumber:
E-mail:
Profession:

Previous treatment method (if any):
Upper lipfacefeetthighsLower liparmpitsshouldersforearmsCheeksbikini linechestupper armsBetween the eyebrowsnavel stripbuttockskneeChinbellybackNeckHandsLower LegsOther
If other is selected, then please fill in what bodypart to treaten

Do you suffer or have you suffered from one or more of the following diseases, tick the box below?
Disease of the (ad) kidneysAllergies, such as photosensitivity or histamine reactionsBlood or clotting disorders, such as thrombosisEndocrinological diseases, such as diabetesHeart disease, such as high blood pressureSkin and/or venereal diseases, such as herpes, psoriasis or eczema, keloidCancer or skin tumorsImmune diseases, such as a weakened immune systemInfectious diseases or inflammationVaricose veins or other vascular problemsHormone imbalance, a decreased estrogen or increased androgen level
Diseases of the nervous system, such as epilepsy or other, namely
If the box is checked, please let us know what diseases of the nervous system you suffer from
Other to know diseases or disorders, namely
If the box is checked, please let us know what other diseases or disorders you suffer from

Are you taking or have you taken any medications such as birth control pills, antibiotics or overuse of aspirin?
yesno
If selected yes, let us know what medicine you use

Do you have a pacemaker, implants, prostheses or other foreign objects?
yesno
If selected yes, let us know what implants you have

Do you use vitamin preparations?
yesno
If selected yes, let us know what preparations you make use off

Do you use any homeopathic remedies or herbal extracts, such as St. John's wort, tea tree?
yesno
If selected yes, let us know what homeopathic remedies or herbal extracts

Are you regularly exposed to sunlight, sunbeds or tanning products?
yesno
If selected yes, let us know what products you use

Do you have permanent makeup or tattoos?
yesno
If selected yes, let us know where

Does your skin have irregularities in structure or pigment, such as pigment spots?
yesno
If selected yes, let us know what kind of irregularities in structure or pigment you have

I hereby declare that I have answered the above questions completely and truthfully and that I will report any changes in this data to the specialist during the next treatment.

Informed Consent Hair Removal | Terms and Conditions:

• Be aware that the treatments will take place at your own risk.

• Aware that success cannot be guaranteed with certainty.

• That one should count on a reduction of approximately 85% to 95%.

• You should always shave, trim or cut yourself 24 hours before the treatment.

• After the treatment there may be redness (erythema) which is normal.

• This disappears within 2 days.

• You should not expose the treated area to sunlight for a week before and a week after the treatment. This also applies to spray tanning products.

• Disturbances in the hormone balance, certain medications or diseases, puberty, pregnancy, breastfeeding, menopause can cause new hair development.

• The skin must not be damaged.

• During the treatment everyone is obliged to wear safety glasses.

• Believe that I have been given an answer about the nature, extent and method of treatment and I have been given the opportunity to have all my questions answered.

• Appointments must be canceled at least 24 hours in advance.

Contraindications:

• Cancer, specifically skin cancer

• Pregnancy (incl. IVF)

• Use of photosensitive medication and herbs for which wavelengths between 265 and 2940 nanometers are a contraindication.

• Diseases that can be stimulated by light between 265 and 2940 nanometers.

• Radiation therapy

• Anemia

• Multiple sclerosis

• Rheumatoid arthritis

• Acute or chronic renal failure

• All chronic diseases e.g. Chrohn's disease

• Bacterial or viral infections

• A disturbed immune system

• Active infection of herpes or eczema in the area to be treated.

• Diabetes (insulin dependent)

• Slightly fragile and/or dry skin

• Hormonal abnormalities (stimulated by intense light)

• Use of anticoagulants

• Epilepsy

• History of coagulopathies

• Isotretinoin-Roacutane or Tretinoin-Retin A in the previous 6 months for acne treatments or other dermatological conditions.

• Hypopigmentation (vitiligo)

• Treating over tattoos or eye or lip liner (except for removing them)

• Implanted pacemaker or defibrillator

• Treating areas with topical medication such as hydrocortisone, make-up, perfumes, deodorant, sun block, essential oils or other skin lotions.

• PUVA treatments

hereby declare that I have understood the above treatment conditions and that I adhere to them at all times. I want to undergo treatment with the Soprano of my own free will and under my own responsibility.

Date:

Full name:

Signature:
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