• Medical History Form

    CONFIDENT IMAGE CHEZ FRANCE
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  • General Health

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  • Medication

  • Treatment History

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  • Terms & Conditions: Ultimately, we are here to help you and want your experience to be a pleasant one. We thrive on providing a safe and effective treatment and wish to assist in any way possible; it is your responsibility over the duration of your treatments to tell us if there has been a change in medication, prescriptions; topical or otherwise, or a change in your health and if you have had others skin care treatments outside our office or a change in home skincare regime and/or product used. Skin reactions can occur though rare, and are avoidable if you follow our standard protocols and recommendations. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

    I confirm that I am not pregnant at this time, and that I have not applied topical Retinol A, Tazorac, Steroid creams or other prescription Retinoids within the last week, nor have I taken Accutane within the last 6 months.  I do not have a pacemaker or internal defibrillator.  I understand that how I take care of my skin after treatment influences my risk of complications.  I agree to follow the clinics recommendations.  I agree to stay out of the sun or tanning beds and to use sufficient sun block for 2 - 4 weeks following my treatment.  I agree to call the clinic if I develop any markings on my skin after treatment, and I will not pick at them.

    I certify that the preceding medical, personal and skin history statements are true and correct.

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