Body Works Consent Forms

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Gender*

I am interested In: (please check all that apply)*

When you sunbathe, how does your skin respond?*

Always burn, never tanUsually burn, tan with difficultySometimes burn, tan about averageAlmost never burn, tan very easily Rarely burn, tan easilyNever burn, always tan

Medical History: Check the appropriate box next to any condition for which you have been treated.*

ARE YOU CURRENTLY BEING TREATED FOR ANY CONDITIONS NOT LISTED? IF YES, PLEASE SPECIFY*

ARE YOU CURRENTLY TAKING ANY MEDICATIONS, INCLUDING HERBAL PREPARATIONS, MEDICAL PATCHES OR ASA? IF YES, PLEASE SPECIFY.*

DO YOU HAVE ANY ALLERGIES? IF YES, PLEASE SPECIFY.*

HAVE YOU EVER USED (OR ARE CURRENTLY USING) RETIN A OR GLYCOLIC ACID? IF YES, PLEASE SPECIFY.*

HAVE YOU EVER USED (OR ARE CURRENTLY USING) ACCUTANE? IF YES, PLEASE SPECIFY*

HAVE YOU EVER HAD A CHEMICAL PEEL? IF YES, PLEASE SPECIFY.*

HAVE YOU HAD ANY LASER TREATMENTS? IF YES, PLEASE SPECIFY.*

WHAT PRODUCTS ARE YOU CURRENTLY USING ON YOUR SKIN?*

DO YOU HAVE ANY DENTAL OR ACRYLIC IMPLANTS, CROWNS OR BRIDGEWORK? IF YES, PLEASE SPECIFY*

DO YOU HAVE ANY TATTOOS OR PERMANENT MAKEUP IN THE AREA TO BE TREATED?*

YesNo

DO YOU HAVE A PACEMAKER?*

YesNo

HAVE YOU EVER BEEN TREATED BY AN ENDOCRINOLOGIST (HORMONE IMBALANCE)?IF YES, PLEASE SPECIFY.*

DO YOU SUNBATHE OR USE SELF TANNING LOTIONS OR USE TANNING BEDS? IF SO, THEN HOW OFTEN?*

HAVE YOU EVER HAD GOLD THERAPY (USED FOR RHEUMATOID ARTHRITIS)?*

YesNo

ARE YOU CURRENTLY PREGNANT?*

YesNo

HAVE YOU HAD FILLER OR BOTOX/DYSPORT INJECTIONS IN THE AREA TO BE TREATED?IF YES, PLEASE SPECIFY.*

DO YOU HAVE ANY PARTICULAR SKIN SENSITIVITIES?*

PLEASE SIGN BELOW TO INDICATE ALL THE INFORMATION ON THIS FORM IS ACCURATE AND COMPLETE.*

I, hereby give my permission to BodyWorks Day Spa and any employees, or any person, firm or organization that she may designate to take photographs, digital images and/or videos of me or, if applicable my (son/daughter)

Patient Name (if applicable)*

Son / daughter Name (if applicable)*

This consent includes the use of such photographs, images or videos without my name for procedure evaluation, patient discussion and medical educational purposes regarding the aesthetic procedure. Additional acceptable uses for such images and videos are initialed below.

1. Photo book
2. Website or social media sites
3. TV broadcast
4. Digital/print article or publication
5. Advertisement

Patient Name*

Parent Guardian Name (if applicable)

Signature*

I hereby authorize BodyWorks Day Spa to perform the Sun Spot Laser Treatment. It may take multiple treatments to obtain optimal results, and it is possible that the results will be minimal or not help at all. The results may be temporary or permanent and there is no way to predict how long the results will last. Although these devices are effective in most cases, no guarantees can be made

The procedure may result in the following adverse experiences or risks:

● DISCOMFORT/PAIN – Some discomfort and/ or pain may be experienced during treatment. A topical anesthetic will be applied to your skin before treatment. Other forms of anesthesia, or pain management, may also be used.
● SWELLING – Swelling (edema) of the treated area is common and may occur. This usually resolves in a few days.
● REDNESS – Redness (erythema) of the treated area is common and may occur. The erythema typically resolves in about two weeks.
● SKIN COLOR CHANGES – During the healing process, there is a possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent. You should avoid sun exposure after the treatment and use sunblock.
● MILIA/ACNE – Ointments that occlude hair follicles, sweat ducts, or sebaceous ducts may lead to milia/acne formation. This is more common in patients with a history of cystic acne or oily skin.
● WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated areas. It is important that you not pick or scratch the sites as this may lead to permanent scars or promote an infection. If any of these occur, please call our office.
● INFECTION – Infection is a possibility whenever the skin surface is disrupted which can lead to scarring. Proper wound care and keeping the treated area clean are important. If signs of infection develop, such as pain, heat, blisters, or surrounding redness, please call the spa at (516) 488-5573 .
● CONTACT/ALLERGIC DERMATITIS OR SKIN SENSITIVITY – Potential increased sensitivity, irritation/itching or allergic reaction of the skin due to skin surface disruption.
● SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post treatment instructions provided by your healthcare staff.
● TREATMENT PATTERN – A persistent spot size pattern may be apparent on the treated skin and usually resolves with time. In rare cases, it may be permanent.
● PETECHIAE – May appear for several weeks after healing and clear without treatment.
● DILATED PORES – Collagen contraction that occurs as part of the resurfacing process may also contract the skin between the pores, which widens the existing pores. This occurrence, though rare, is permanent.
● SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING – May increase risk of side effects and adverse events.
● ALLERGY – There is a risk of an allergic reaction to the topical anesthetic or the metal needles

I acknowledge the following points have been discussed with me:
● Potential benefits of the proposed procedure, including the possibility that the procedure may not work for me
● Alternative treatments
● Reasonably anticipated health consequences if the procedure is not performed
● Possible complications/risks involved with the proposed procedure and subsequent healing period

For women of childbearing age: By signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of treatment. Furthermore, I agree to keep the BodyWorks Day Spa staff informed should I become pregnant during the course of treatment.

Photographic documentation will be taken. I hereby do do not authorize the use of my photographs for teaching purposes.

ACKNOWLEDGMENT

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS INFORMED CONSENT FOR THE SECRET RF TREATMENT, AND THAT I HAVE HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION BY MY HEALTHCARE TEAM.

Name*

With your signature you agree to today and all future treatments of this service.

Signature*

Vascular Health History / Consent Form

Video and Release Form