arcticmedicalcenter.com - Contraindications Consent Form

Please note the following contraindications for the laser treatment you may be receiving. Please mark the following accordingly:

	Yes	No
Sun Exposure to the treatment site within the past 3-4 weeks
Sunless tanning to treatment site (spray tan/tanning lotion) within the past 3 weeks
Retinol/Retin-A/Hydroquinone to the treatment site within the past 3 days
Use of Accutane within the past 6 months
Active cold sore/fever blister
Pregnant/lactating
Active infection
Immune system disorder
History of skin cancer
Diabetes
Use of anticoagulants/NSAIDS within the past 3 days
Cancer/cancer treatment within the last 12 months

By signing you acknowledge the listed contraindications of the use of Spectrum Laser treatments.
Patient Name:

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Contraindications Consent Form for use of Spectrum Laser Treatments