Medical History Form

Answer each question prior to your laser treatment. Check NO or YES. If YES, explain

Natural or artificial sun exposure in the past 3-4 weeks pre- or post-treatment

Use of self-tanners or tan enhancers caps within the past 3-4 weeks

Photosensitive herbal preparations (St. John’s Wort, Ginkgo Biloba, essential oils)

Diseases which may be stimulated by light at 805nm, 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 (scarring of the skin)

History of livedo reticularis (rash that causes lace like purplish discoloration of the skin)

History of erythema ab igne (rash that causes hyperpigmentation, scaling, and redness to the skin)

Intake of isotretinoin within the past 6 months

Medical history of Koebnerizing isomorphic diseases (such as vitiligo, psoriasis)

Any known allergy

Any tattoo and/or dysplastic nevi (skin cancer or precancerous skin lesions) on requested treatment area.

Intake of aspirin or anti-coagulants

Easy bruising

Hormonal or endocrine disorders (such as PCOS or uncontrolled diabetes)

Previous hair removal procedures on requested treatment area (other IPL/laser, wax electrolysis, etc) within the past 6 weeks

Previous skin procedures on requested treatment area (Botox, fillers, peels, etc.…)

List of current medications:

My signature certifies that I have read and understand the content of the consent form and have provided accurate information regarding my health. I freely consent to LightSheer DESIRE laser treatments given by Renew Laser and Aesthetic Medicine.

Thanks for submitting!