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.
