Please read carefully and initial:
I have not used retin-A for 72 hours
I do not have any active cold sores.
I acknowledge that there is a rare possibility of an allergic reaction. I have previously used alphahydroxy acid products on my skin and/or in the past with no allergic reaction, but understand there still could be a response.
I agree to avoid direct sun exposure for 48 hours.
I agree to notify my esthetician of any concerns.
I agree not to wax for 72 hours pre/post treatment.
There will be a $50 charge for patients who aren't shaved and need shaving. Your appointment may have to be rescheduled if you do not come shaved and our schedule does not allow enough time to perform your treatment.
We have a 24-hour cancellation policy. You will be changed full price for all appointments that are a no show and $25 for appointments that are cancelled in less than the 24 hour period. You must have a credit card on file at all times while receiving treatments at Blue Divine due to this cancellation policy. No refunds.
CONFIDENTIAL MEDICAL FORM
To avoid unforseen complications, please answer the following questions:
Please check any of the following that may pertain to you:
Please explain any checked questions and list any other medical conditions and all medications currently being taken:
Doctor's Name: Phone:
AFTER CARE FORM
Post Treatment Instructions:
1. Immediately after the treatments, you should apply an ice pack, as there may be mild swelling. It is normal for the treated area to feel like sunburn for a few hours. You should use a cold compress if needed. Avoid any trauma to the skin for up to 2-5 days, such as bathing with very hot water, strenuous exercise, or massage.
2. Avoid picking or scratching the treated skin to achieve your best results. If any crusting, apply antibiotic cream. Some physicians recommend aloe vera gel or some other after sunburn treatment such as Desitin. Darker pigmented people may have more discomfort than lighter skin people and may require the aloe vera gel or an antibiotic ointment longer Follow instructions as
specified by your laser professional.
3. Makeup may be used after the treatment has quit swelling unless there is epidermal bleeding. It is recommended to use new makeup to reduce the possibility of infection. Keep the area moist. Any moisturizer without alpha-hydroxy acids will work.
4. You may shower after the laser treatments in tepid water. The treated area may be washed gently with a mild soap. Skin should be patted dry and NOT rubbed.
5. You will experience redness and bruising from five to fourteen days at the treatment. Avoid direct sun exposure and tanning beds for 1-2 months and throughout the course of the treatment so as to reduce the chance of dark or light spots. Use sunscreen SPF 25 or higher at all times throughout the treatment when going outside.
6. Avoid tweezing, waxing, bleaching or chemical peels during the course of the treatment. Do not use any irritants such as Retin-A, Benzoyl Peroxide or astringents.
7. Call your physician’s office with any questions or concerns you may have after the treatment
Patient Consent Form
REJUVAPEN SHOULD NOT BE USED BY PATIENTS UNTIL THERE HAS BEEN A COMPLETE DISCUSSION OF THE RISKS AND WRITTEN INFORMED CONSENT HAS BEEN OBTAINED.
My treatment with the REJUVAPEN has been personally described to me by Blue Divine Aesthetics.
The following points of information, among others, have been specifically discussed and made clear and I have had the opportunity to ask any questions concerning this information:
1. I, , (patient's name) understand that REJUVAPEN will be used to treat skin tightening, Acne scars, Wrinkles or Lift & Firm of the skin. I have been examined by my physician and have been cleared for this procedure.
2. Any and all follow-up treatment (if necessary) needs to be scheduled witha licensed medical provider to determine if additional treatments are necessary.
3. I understand that most patients look as though they have a moderate to severe sunburn and my skin may feel warm and tighter than ususal. Most patients usually recover within 24 hours or less. Because the device may penetrate the skin there can be a risk of infection, if this occurs, a follow up appointment willl be required for further treatment.
4. Rejuvapen may not be used directly on any of the below conditions. I have disclosed any of the health concerns below that apply to me:
- Open sores or lesions
- Skin cancer
- Broken or irritated skin, including conditions such as hives or dermatitis
- Any stage of melanoma
- Raised Surface
- Active Acne
- Any type of skin infection?
I now authorize Blue Divine Aesthetics to begin my treatment with Rejuvapen.