Have you tested positive to Coronavirus? No Yes If yes selected, we will be unable to perform a treatment for you at this time.
Do you have or have you experienced any of the following conditions?(Please indicate if any)
Are you taking any of the following medications and supplements?Herbal preparations, food supplements or vitamins that might cause fragile skin or impaired skin healing such as prolonged steroid regime, Isotretinoin (Accutane), tetracyclines, or St. John's Wort. No Yes If yes, please specify: medications / supplements
Have you had Aesthetic procedures in the treatment area, such as:Fillers: No Yes If yes, please type name of filler: Type of filler . Date treated: Treatment Date Gold / plastic threads: No Yes Fat implants: No Yes Other, please specify: Other Aesthetic procedures
I, the undersigned, pledge to inform of all changes in my physical condition. I agree to undergo the treatment, as detailed below in this document. I was explained to and I understood the results, the chances and the course of the treatment.I confirm that I do not suffer from any of the above described conditions.I have had the opportunity to consider the following information, ask questions and have had these answered satisfactorily by (therapist) .
TriPollar is a radiofrequency (RF) technology indicated for the treatment of facial wrinkles and rhytides. The RF energy heats the skin’s dermal layer to stimulate a process of new collagen production and tightening of the existing collagen.
I confirm that I have read and understand the above information and consented to the treatment out of my own free will.
Client Name: Client Name Date Signed Date
Therapist Name: Client Name Date Signed Date