Patient or Parent/Guardian Name:
Cell Phone Number:
Home/Alternate Phone Number:
Gender: Date of Birth:
*May we contact you by email and phone?
BOTH Email and Phone
Getting to Know You
How were you referred to our office?
Patient / Friend
Email / Internet Promotion
TV / Radio Commercial
What is the primary reason for your visit?
Do you go to the Gym, Spa, etc.?
*What is your average household income?
*What is your budget to spend on services provided?
What is your occupation?
*NAME of your emergency contact:
*Relationship of your emergency contact:
*Emergency contact's Phone #:
Emergency contact's email:
Skin History Questions
What is your current method of hair removal?
What is the hair color in the area of interest?
Which best describes your skin tone?
Uneven Skin Color
Which best describes the firmness and elasticity of your skin?
Loss of Firmness Elasticity
Which best describes the texture of you skin?
What is the area of interest for Cellulite Reduction/Body Contouring/Circumferential Reduction?
*Do you have or have you ever had any of the following conditions:
*Do you have or have you ever had any of the following conditions?
If you answered YES to any of the conditions listed above, please specify:
*Surgical History - Do you have or have you had?
If you answered YES to any Surgical History above, please specify:
*Medication History - Do you take?
If you answered YES to any Medications mentioned above, please specify:
*Allergies - Do you have?
If you answered YES to having any allergies mentioned above, please specify:
*Other Procedures - Have you had the following?
If you answered YES to any of the other procedures mentioned above, please specify:
*Do you use any of the following products?
If you answered YES to using any of the products mentioned above, please list the product brand name and frequency:
Skin Type Calculator
*What is your natural hair color?
*Color of your skin?
*Color of your eyes?
Light Blue, Green
Brown / Black
*Do you have freckles?
*What happens when you are overexposed to the sun?
Burns, Sometimes Peels
*To what degree does your skin turn brown (Tan)?
Hardly/Not at all
Light Color Tan
Turns Dark Brown quickly
*Do you turn brown within several hours after sun exposure?
*How does your face react to the sun?
*When was your last exposure to sun, lamps or cream?
More than 3 months
Less than 1 month
Less than 2 weeks
*Was the treatment area exposed?
*Which of the following ethic backgrounds apply to you?
|Patient or Parent/Guardian Signature:
MESOPEN TREATMENT INFORMED CONSENT FORM
My treatment with the Microneedling has been personally described to me. The Risks, Benefits, Complications, No Results Guaranteed, Alternative options (including doing nothing) to Microneedling have been explained to me. The following points of information, among others, have been specifically discussed and made clear and I had the opportunity to ask any questions concerning this information:
I understand that Microneedling helps improve Wrinkles, Fine lines, Acne scars, Lift & Firm the Skin, For Skin Tightening, Help diminish Age Spots & Sun Spots, Help Improve Skin Texture, Tone & Pigmentation and Improve Discoloration.
NO RESULTS ARE GUARANTEED
PROCEDURE MAY NOT WORK AT ALL AND SHOW NO IMPROVEMENT IN WRINKLES OR DISCOLORATION
I understand that most patients look as though they have a moderate to severe sunburn and my skin may feel warm and tighter than usual. This is normal and will subside after 1 to 2 hours. Most patients usually recover within 2-3 days or less.
Pain is an important factor to prevent adverse events during the procedure. If your pain is more than 4 on a scale of 10, you must ask the staff to STOP the procedure. Pain scale - 1 being the least and 10 being the worst pain you have ever had.
Nature of the Microneedling Procedure
The purpose of this procedure is to improve wrinkles, fine lines, texture, tone, pigmentation & discoloration of skin
Possible Alternative Procedures -
Alternative methods include Laser Skin Resurfacing with Ablative or Non-Ablative Lasers eg Fraxel or CO2 or not do anything at all.
Potential Benefit and what to reasonably expect –
Improvement in wrinkles, fine lines, texture, tone, pigmentation & discoloration of skin
No Results Guaranteed. This program will require multiple treatments. The goal of Microneedling, as in any cosmetic procedure, is improvement, not perfection.
COMPLICATIONS (which can be PERMANENT) - of this procedure include but are not limited to
- Scarring – can occur when the skin surface is disrupted / when a burn heals. Follow post procedure instructions carefully to minimize the risk of scarring
- Discoloration - Skin Color changes, either lighter (hypopigmentation) or darker (hyperpigmentation) may occur. Usually temporary but can become permanent
- Skin Infection
RISKS of this procedure include but are not limited to –
- Pain / Discomfort – Many pts describe the sensation as ‘warm heat sensation’ or snap of a rubber band with pain scale of 2 to 3. It is your responsibility to inform us if your pain during the procedure is more than 4 on a scale of 10. 1 being the least and 10 being the worst pain you ever had.
- Redness or Swelling – hive like reaction
- Bruising or increased broken capillaries
- Blister/Scab and Skin Infection
- Skin Dryness &/or Discomfort
- Mismatch in color, tone or texture of the skin
- Tenderness or mild tingling
- Sun Sensitivity - temporary increased susceptibility to sunburn
- Acne Breakout
- Activation of Fever Blisters (herpes)
- Melasma – may get worse
- Rosacea – may get worse
- Drug reactions or interactions
CONTRAINDICATIONS of this procedure include but are not limited to –
- History of keloid scarring or abnormal wound healing
- Tattoos, active sores, rash (psoriasis, eczema) or infection in the treatment area
- Any internal metal device, i.e. surgical screws, pins, plates, or implants in the area to
- Hormonal imbalance, pregnancy and menopause can affect treatment outcomes
I have disclosed any or all of the following health concerns:
- 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 infections
Tattoos (and ‘permanent’ makeup) - We do not perform Microneedling procedure over the tattoo, unless specifically approved by the physician. Doing this over tattoo may damage or lighten it and increase risk of scarring and discoloration.
- I authorize the taking of photographs or videotapes, or other similar means of recording the treatment
- I understand that my privacy will be protected and will in no way reveal patient identity
- I understand that these recordings may be used for documenting progress of my treatment and outcomes, illustrating the medical procedure, medical study, research, publication and marketing.
- I give permission to use and publish the same in whole or in part, individually or in conjunction with other photographs, in any medium for any purpose, including art, illustration, promotion, advertising or trade
- Failure to allow the taking of photographs of my treatments will make it impossible to judge the efficacy of my treatments and will void any extended treatment program, guaranty and/or any treatment beyond those included in the purchased package.
- I give permission to American Laser Med Spa to copyright the same in their name or any other name that they may choose
- I hereby release American Laser Med Spa and its agents from any and all claims and demands arising out of, or in conjunction with the use of the photographs
I certify that I have read this entire consent and I agree to all the information presented to me in the clinic and in this consent form & the pre/post procedure instructions. A member of the ALMS staff has explained the following:
- No results are guaranteed
- Nature of the procedure
- Alternative procedures
- The potential benefits & what to reasonably expect after undergoing this procedure & limitations
- The complications, risks and contraindications of this procedure
- Benefits of this procedure over the alternatives
- I have had ample opportunity to ask any questions regarding the procedure, side effects and after care, and all of my questions have been answered to my satisfaction. I believe I have adequate knowledge to understand the nature and risk of the treatment to which I am consenting.
- Upon request, I have been given copies of the consent and pre/post care instructions.
I understand the procedure and accept the risks, and request that this procedure be performed by a provider at American Laser Med Spa.
I agree that this consent supersedes any previous verbal or written disclosures. This consent is valid for all my Microneedling Treatments in the future as well.
Patient or Parent/Guardian Signature:
MICRONEEDLING - PRE & POST PROCEDURE INSTRUCTIONS
For your safety & to get optimum results, please follow these instructions
Before Treatment -
- PAIN – Tell us to stop the procedure if pain is more than 4 on a scale of 10 during treatment. Most patients feel pain scale of 2 to 3.
- If the treatment area is face, preferably come with your makeup off
- Do not use on treatment areas – any skin lightener, exfoliation products or bleaching creams 2 days before and 2 days after treatment or until all pinkness has subsided.
- Do not apply any creams, lotions or deodorant on the area to be treated prior to treatment.
- Notify us of any change in medications or medical history since last visit –eg Pregnancy or new tattoos or moles (on the area of treatment)
After Treatment -
- After you leave the clinic, if there are any problems in the next 24 hours, please contact the clinic immediatelyespecially if pain or burning sensation at level 4 or more and is not improving OR if a burn or a blister formation has occurred.
- After treatment, avoid direct sun exposure or tanning on treated area for 3 days to prevent complications
- Use Sunscreen - Sunscreen SPF 30 or higher is highly recommended
- To wash, use tepid water and mild soap. Do not use hot water on freshly treated areas until pinkness has subsided
- Please note the important risks of this procedure – Scarring & Discoloration that can be permanent
If you have any questions or concerns, please contact our Office.
I have read and understand the instructions and realize to get optimum results I must follow these instructions diligently.
|Patient or Parent/Guardian Signature:
TREATMENT AND FINANCIAL AGREEMENT TERMS, CONDITIONS, DISCLAIMERS AND REFUND POLICY (EFFECTIVE 4-14-2010)
- I fully understand and agree to treatment of the listed areas, and agree to pay American Laser Med Spa the price quoted above.
- If I have paid the price quoted using a credit program, I acknowledge that I have selected the credit program based on my own evaluation of my options. I have not relied on any recommendation or advice of American Laser Med Spa or its staff with respect to financing. I understand that American Laser Med Spa has agreements with credit program providers but does not recommend credit products to customers
- I clearly understand that my payment is for the procedure(s) performed during the term of the agreement and not for any specific result. NO RESULT IS GUARANTEED. I understand that results will vary.
- Additional treatments may be obtained at an additional price.
Refund, Cancellation and Transfer Credit policy
Your payment is based on purchasing number of treatments. Refund is based on unused treatments not based on unused time. e.g. Laser Hair Removal Series – Your payment is based on purchasing 6 treatments. NOT 2 yrs. In the 2 yr appearance plan phase (after your 6th treatment), we reserve the right when to treat you and how many times to treat you. If you receive 6 treatments, no refund is due. All refund prorating will be based on unused treatments. There is no prorating for time. e.g. If you purchased a package of 6 and received only 4 treatments in 8 months and request a refund. You have 2 unused treatments and 16 months left before your 2 yr appearance plan expires. A prorated refund (see below) will be given for 2 unused treatments, NOT based on remaining 16 months.
THIS POLICY WILL BE VOIDED IF YOU TRANSFER SERVICES TO ANOTHER LOCATION AND WILL BE REPLACED BY THE RECEIVING CLINIC’S CURRENT POLICY
If you want to cancel services and want refund –
You WILL BE charged FULL PRICE PER TREATMENT of the procedure. The price per treatment of the procedure you purchased is on our price list sheet and will be provided to you on request. All discounts (e.g. monthly specials) and credits issued when you bought the service will be lost. Service will be prorated using price per treatment listed on the price list sheet. If you earned friends and family credit - this will be LOST if you cancel/break this agreement. A prorated balance will be refunded
If you want to cancel services and don’t want a refund but want to transfer credit to another package –
You will NOT be charged FULL PRICE per treatment of the procedure to calculate prorated balance. You will be charged the price per treatment based on your package. The balance will be used towards a new package. You will be eligible for the month’s special etc. If this results in you owing money, you can pay the difference and start the new package. If this results in us owing you money, this will be kept as credit for future use. (Credit expires 90 days from new purchase).
If you don’t see results even after 2 yrs of treatments for Laser Hair Removal - NO REFUND is due. You can buy a new package at 2 yr appearance plan (maintenance) price.
If you are burned or have other adverse event – NO REFUND is due. This is part of the risk of the procedure and was explained to you when you signed the contract. Our goal is to eliminate/minimize the risk of burn or any other adverse event, but we want to be upfront with you so you can make a well informed educated decision.
- No Show Fee - $75. If you do not show up for your scheduled appointment
- Cancellation Fee - $75. If you cancel appointment without giving us a 24hr notice
- Shaving Fee - $75. If you come in without shaving (exception – first treatment or unless we asked you not to shave)
- Photocopying Fee - $10. For a copy of your records. Need a written request.
I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE.
|Patient or Parent/Guardian Signature: