TriPollar/TriLipo Consent Form
Personal Information and health questionnaire
Existing or recent illness:
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