Radiofrequency Microneedling Consultation ForM Name First Name Last Name Date of Birth Occupation Email Phone (###) ### #### Area of treatment Tick one Face Body Medical history: Please mark any that apply to you Pregnancy or nursing (current only). Pacemaker or internal defibrillator, implanted neurostimulators or another internal electric device. Current or history of, cancer - especially skin cancer, or pre-malignant moles in treatment area. Diabetes and Impaired immune system due to immunosuppressive diseases such as AIDS and HIV. Immune suppressive medications. Medications such as blood thinners. 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. Areas of sensory impairment such as in cases of nerve lesions and neuropathies. Any active condition in the treatment area, such as sores, psoriasis, dermatitis, eczema and rash as well as excessively/freshly tanned skin. If getting the Face treated: Dental implants, braces, caps, metal fillings (amalgams, gold) Botox or filler in treatment area. Active weeping acne. Continuous use of Retin A, retinol or any other Vitamin A derivatives. Herpes (active). Allergies, If known, please list specific offending ingredients: Any surgical, invasive, ablative procedure in the treatment area before complete healing. Any medical condition that might impair skin healing If getting the BODY treated: Heavy menses/bleeding. Metal implants or other implants in the treatment area- i.e. IUD, screws, plates. Varicose veins in the treatment area. If you answered YES to any of the above, please explain: Please list any medications and supplements you are currently taking: I confirm that the medical history is accurate and complete. Therefore, if there are any adverse effects due to an undisclosed medical condition, our therapists are absolved from any responsibility. I understand that withholding any medical information may be detrimental to my health and safety during which the practitioner agrees to undertake. It is my responsibility to advise my practitioner if there is any change in my medical history. Thank you for filling out the form!
