PATIENT PROFILE

Please read and initial each statement.

initial here* I authorize Limitless Medspa Licensed Laser Hair Removal Technicians to perform treatments on me for Hair Reduction / Pigmented Lesions / Vascular Lesions / Skin Treatment / Nail Fungus / Warts / Other.

initial here* I understand that there is a rare possibility of side effects or serious complications including skin burns, permanent discoloration, and scarring. I am aware that careful adherence to all advised instructions will help reduce this possibility.

initial here* I understand the below list of short-term effects and agree to follow matching guidelines:

Discomfort – during the procedure and shortly after, I might experience an itching/ tingling sensation which degree will vary per condition density and area sensitivity. A mild “sun-burn” sensation may follow for a couple of hours and will be reduced with application of cooling and soothing creams
Erythema/edema – severity and duration will depend on the intensity of the treatment and the sensitivity of the area to be treated. This redness/swelling may be reduced with application of cooling and/or inflammatory creams
Crusting over some dense pigmented areas – may take 5 to 10 days to flake off and it is important not to manipulate or pick which may otherwise lead to scarring
Bruising if your skin is prone to it or over dense vasculated areas – may last several days

initial here* I understand that recent sun exposure or tanning of any sort is not aligned with the pre and/or post-care instructions and may increase the chance for complications.

initial here* The procedure, as well as potential benefits and risks, have been thoroughly explained to me and I have had all my related questions answered

initial here* Pre and post-care instructions have been discussed and are completely clear to me.

initial here* I understand that results may vary with each individual and acknowledge that it is impossible to predict how I will respond to the treatment and how many sessions will be required.

initial here* I consent to photographs being taken for the purpose of documenting my progress and response to the treatment and being kept solely in my medical record.

initial here* I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity.

initial here* I agree to review the following laser pre-treatment compliance checklist along with my Physician and bring accurate and updated data, to the best of my knowledge.

Skin type of the area to be treated: *

I II III IV V VI

Please select your your response to each situation/condition/symptom: *

	No	Yes
Natural or artificial sun exposure in the past 3-4 weeks pre-op or the following 3-4 weeks post-op plan
Use of self–tanners or tan enhancer caps within the past 3-4 weeks pre-op plan
Photosensitive herbal preparations (St John’s Wort, Ginkgo Biloba, etc…) or aromatherapy (essential oils)
Diseases which may be stimulated by light at 755nm and/or 1064nm, such as history of Systemic Lupus Erythematosus or Porphyria
Pregnant or possibility of pregnancy, postpartum or nursing
Inflammatory skin conditions (dermatitis, active acne, etc...)
Presence or history of active cold sores or herpes simplex virus
HIV
Active cancer (currently on chemotherapy or radiation)
Previous skin cancer?
Medical history of keloids
History of livedo reticularis
History of erythema ab igne
Intake of isotretinoin within the past 6 months
Medical history of Koebnerizing isomorphic diseases (vitiligo, psoriasis)
Hormonal or endocrine disorders (PCOS or uncontrolled diabetes?)
Any tattoo and/or dysplastic nevi on requested treatment area that should be protected?
Intake of aspirin or anti-coagulants?
Easy bruising?
Swollen legs or pain after long standing/sitting?

Any known allergy? *

Yes No

If yes, please list allergy and reaction

Date of latest blood tests *

Date

Any hormonal imbalance? *

Yes No

If yes, explain which levels:

Any previous hair removal procedures on requested treatment area (other IPL / laser, wax, electrolysis, etc.…) Within the past 6 weeks? *

Yes No

If yes, list procedure(s) and procedure date(s):

Any previous skin procedures on requested treatment area (Botox, fillers, peels, etc...) *

Yes No

If yes, list procedure(s) and procedure date(s):

List of additional current medication taken or other health conditions to be noted: *

My signature certifies that I have duly read and understood the content of this informed consent form, and gave accurate information as to my health condition.

I hereby freely consent to SplendorX treatments.

Patient Name *

First Name Last Name

Patient Signature *

Clear

Date *

Date

LASER HAIR REMOVAL CONSENT FORM