Test - Virtual Biznest

Birthday (M D YY)

A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area

YES

Aesthetic Procedures

Allergies

Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/freshly tanned skin

YES

Any medical condition that might impair skin healing

YES

Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing

YES

Business Telephone

Current or history of cancer, especially skin cancer, or pre-malignant moles

YES

Date Signed

Email Address

Employment

History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile Skin

YES

Hospilazation/Surgery

ID Number

Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications

YES

Medical Director Name (Print)

Medical Director Signature

Medications

Name

Patient Name (Print)

Patient Signature

Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical substance

YES

Phone

Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction

YES

Provider Name (Print)

Provider Signature

Recent or Existing Illness

Severe concurrent conditions such as cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidney diseases

YES

Tattoos, permanent make-up, pigmented lesions (to be kept)

YES

Under 18 years of age

YES

Use of Isotretinoin (Accutane) within 6 months prior to treatment

YES

HAIR REMOVAL Consent Form

Personal Information:

Name

Date of Birth

ID Number

Employment

Home Address

Email Address

Cell Phone Number

Business Telephone

Health Questionnaire:

Recent or Existing Illness

Details

Hospitalization / Surgery

Details

Medications

Details

Allergies

Details

Aesthetic Procedures

Details

Medical History - Please inform physician or assistant prior to treatment if you have any of the following conditions that may make you unsuitable for TRITON treatments.

Pregnancy or nursing
Under 18 years of age
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 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
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 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

Specific Informed Consent for TRITON Treatments

This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with TRITON technology. If you have any questions before your treatment, please feel free to ask.

I hereby authorize (provider name) to perform the TRITON procedure.
The physician obtained my medical history and found me eligible for treatment.
I have received the following information about the technology: The procedures to be used to treat my conditions have been explained to me.
- TRITON is a non-invasive technology that utilizes Diode laser, for hair removal with highest speed, the best skin cooling system for hairs of dark blond-black color
- No complete clearance is guaranteed
- Treatment requires a number of sessions
- Exact number of sessions is individual
- There may be some discomfort and transient redness and/or swelling associated with treatment
- There is a small risk of adverse reactions
I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.
I was told about the possible side effects of the treatment including: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, burn), change of pigmentation (hyper- or hypopigmentation), and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.
I understand that I have to comply with treatment schedule, otherwise results may be compromised.
I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician or assistants to perform such other procedures if they find them professionally desired.
I understand that not everyone is a candidate for this treatment and results may vary therefore, there is no guarantee as to the results that may be obtained

Patient Initials:

Provider Initials:

I have had sufficient opportunity to discuss my condition and treatment. I believe I have adequate knowledge upon which to base an informed consent.
Any questions I may have asked have been answered to my satisfaction.
I authorize before, during and after the procedure(s) the taking of photographs to be part of my patient profile that may be used for internal purposes without disclosing my identity (eyes will be masked in the photographs).

Patient Signature

Provider Signature

Patient Name (Print)
(Or person authorized to sign for patient)

Provider Name (Print)
*

Date

Medical Director Signature

Medical Director Name (Print)

×

Cart