Medical Release Form
Confidential Client Medical History
City State Zip Code
Cell Phone Work Work
May we text you appointment reminders? Yes No
If yes, please provide your telephone carrier name
How did you hear of us?
General Medical History
Have you had a negative reaction to chemical peels? Yes No
Existing Skin Conditions (Check all that apply)
What skin care line(s) do you use?
Allergies (Check all that apply)
Please list any other allergies below:
Medical and Dietary Supplements
What oral medications are you presently taking?
Do you regularly take Baby Aspirin, Coumadin or other Blood Thinners? Yes No
What topical medications or creams are you currently using?
Are you on photosensitizing medications such as Tetracycline or Retin-A? Yes No
Do you take fish or flax oil supplements? Yes No
Ginkgo? Yes No
What other dietary supplements do you take regularly?
Female Clients Only
Are you pregnant or trying to become? Yes No
Are you breast feeding? Yes No
Are you using hormonal contraception? Yes No
When is your next period
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, doctor or nurse of my current medical or health conditions and to update this history. I understand there are no refunds offered on unwanted treatments and no returns are given for treatments with unsatisfactory results.
Consent for Laser Treatment of Toenail Fungus (Onychomycosis)
Procedures: Toenail Fungus Treatment
Lasers: Quanta Nd:YAG 1064nm
I hereby authorize and direct any associates or employees of Vasu, Inc to perform laser treatment of onychomycosis (toenail fungus) on me. The Nd:Yag 1064nm wavelength laser can treat most toenail fungus by penetrating the nail and destroying the fungus in and under the nail
bed. I specifically acknowledge that no guarantees or warranties have been made concerning the results of the procedure.
The following points have been discussed with me and I understand: (please initial each statement)
Please note that we are not able to diagnose toenail fungus. We are able to treat toenail fungus which has been diagnosed by a licensed physician.
The laser has a controlled thermal effect and it is normal to feel a heating sensation.
I understand that the Nd:Yag 1064nm laser is being used for the treatment of toenail fungus and that my results are not guaranteed.
Lifestyle choices and hygiene may affect my results. Please refer to the post care documents for additional information.
In clinical studies there have been no adverse reactions, injuries, disabilities or known side effects. As with any procedure there is some risk of side effects that are unknown.
Close adherence to the post care documents for toenail fungus will improve your results.
I understand that photographs may be taken before and after the procedure.
I understand that the fungus may not be completely destroyed and that the nail may become re-infected. Your nail may continue to be discolored and may not attach to the nail bed. It may take up to 1 year for the healthy toenail to grow back.
Eye protection must be worn at all times during the treatment.
I hereby authorize Vasu, Inc or any associates to take pictures of the treated area to be used in my patient file and/or teaching purposes. I understand that the release of this information will be kept confidential and that no patient names will be used.
I understand that multiple treatments may be needed.
I have been given the opportunity to ask questions about the procedure(s). My questions have been answered and I understand the information given to me.
Please arrive to your appointments with clean feet and toenails which are free from polish and other products. Please clip and file your nails before each treatment as we are not able to clip or files your nails for you. Failure to adhere to this request will consequent in rescheduling your appointment and holding you to a $50 late cancellation fee.
I recognize that the practice of laser medicine is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures and thus no monetary refunds will be issued to me on any previous or future treatments.
I understand that it is my responsibility to schedule follow up appointments in 1-2 weeks and then again in 3 months after my first treatment is performed.
I have received, read and understand the post care instructions..
I understand that there are no monetary refunds on purchased packages.
I understand and agree to give at least 24-hour cancellation or re-scheduling notice and I agree to pay a minimum of $50.00 or forfeit my treatment if I don’t give proper notification.appointments.
I understand that I release Vasu, Inc and its associates, the Medical Director, the laser technician performing the procedures and any other person involved in my treatment from any liability associated with complications from the laser procedure. By my signature below, I certify that I have read and fully understand the contents of this permission and authorize the performance of laser hair reduction by the staff of Vasu, Inc.
(PURSUANT TO 45 CFR 164.508)
“This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.”
Vasu Skin Solutions is dedicated to protecting the private and medical information of our patients.
It is our firm policy not to share any client information without written permission from the client. Below is a brief summary of our policy and disclosure permission form. If you already have someone in mind that might need access to your medical records, please list that person below.
Vasu’s, policy was put in place to protect your “protected health information” or “PHI”. Therefore we will not discuss any information with you, or anyone else, without first verifying your identity by date of birth, address and getting your written permission to do so.
Your PHI will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers if desired, laboratories and health insurance payers as it necessary and appropriate for your care. Your signature below indicates that you understand and accept Vasu, Inc’s privacy policies. The full description go our privacy policies are located here: www.vasuskinsolutions.com/about-vasu/policies
Release of Information (Check the appropriate boxes and complete the requested information)
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:
Information is not to be released to anyone except self.
This Release of Information will remain in effect until terminated by me in writing.
Please call my home my work my cell number:
If unable to reach me:
you may leave a detailed message
please leave a message asking me to return your call