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:
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.
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
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?
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.