top of page
Home
Book Now
Shop
Lash Aftercare Products
Skincare
Professional Wholesale
Training
Private training
Lashes
Upcoming Classes
Service Menu
Eyelashes
Eyebrows
Facials
Injections
Make-up
Hair Removal
Body Contouring
Learn More
Professional Eyelash Extensions
Eyelash Extension Training
Derma Fillers
Lash Extension Supplier
Mircoblading
Body Contouring
Memberships
Lash Membership
Hair Removal
Contact
About
Forms
Terms & Conditions
Gift Card
More
Use tab to navigate through the menu items.
Log In
BOOK NOW
TriPollar/TriLipo Consent Form
Personal Information and health questionnaire
First Name
Email
Address
Last Name
Phone
Birthday
Existing or recent illness:
Hositalization/ surgery:
Medication:
Medicine intolence:
Esthetic proceduce in the treatment area:
Have you experienced any of the following conditions? (Please indicate if any)
Under 18 years of age.
Pacemaker or inernal defibrillator, implanted neuro-stimulators or any other internal
Metal implants or other implanted in the treatment area.
Pregnancy or nursing or treatment on abdormen during the menstrual cycle.
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 or epilepsy.
Condition which could be adversely affected by heat. A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area.
Diminished or exaggerated perception of temperature changes.
Areas of sensory impairment such as in cases of nerve lesions and neuropathies.
Any active condition in the treatment area such as sores, hemorrhages or risk of hemorrhages, septic conditions, psoriasis, eczema and rash as well as irritated or damaged skin due to excessive fresh tanning.
Varicose veins in the treatment area.
History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.
Any surgical, invasive, ablative procedure in the treatment area before complete healing.
Any medical condition that might impair skin healing.
None of the above
Continue
bottom of page
