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Intake laser

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Name*
Address*

The following questions are about your overall health and medical history. Please answer them as accurately as possible.

Are you healthy at the present time?*
Kidney or Adrenal Disease?*
Allergies, such as photosensitivity or histamine reactions?*
Blood or clotting diseases, such as thrombosis*
Endocrinological diseases, such as diabetes*
Heart disease and/or increased/decreased blood pressure?*
Skin and/or sex disorders, such as psoriasis?*
Immune diseases, such as a weakened immune system?*
Infectious diseases or active inflammation?*
Cancer or skin tumors?*
Skin lesions associated with vesicles/blisters?*
Sensitivity Disorder: Pain, Tingling, Numbness?*
Varicose veins or other vascular problems?*
Disturbed hormones?*
Disrupted wound healing or abnormal scar formation?*
Neurological disorders, such as epilepsy?*
Do you use or have you used medication?*
Do you have a pacemaker, implants or other foreign objects?*
Do you use homeopathic remedies or herbal extracts, such as St. John's wort?*
Are you regularly exposed to sunlight, tanning beds or do you use self-tanning creams?*
Do you have permanent make up or a tattoo in the area to be treated?*
Are you currently undergoing treatments with a doctor, specialist or other skin professional?*
Are you pregnant, are you breastfeeding or do you want to become pregnant?*
Do you have fillers?*
Do you agree that we take before & after photos to assess the progress of your skin and share them on Social Media (without facial recognition)?*

I have answered all questions truthfully. It has been emphatically made clear to me that not answering the questions correctly or incompletely and not complying with the conditions can have a negative influence on the result of the treatment.

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Permission*

Informing consent I hereby confirm that we have discussed the nature of my condition, the treatment I wish to receive, any alternative methods, the general nature of the treatment proposed, the prospects for success and the potential risks and benefits of such treatment . I hereby give permission to the skin therapists of Gentle Skin Clinic to treat me with the Quanta Q-Plus C EVO, Hydrafacial, Elite+/iQ laser, Cryopen, SmartXide Punto CO2 laser, Dermapen (4), MCT Injector, SkinCeuticals, Skintech and/or Mesoestetic products or any other treatments that, in the opinion of the skin therapist, are desirable for my well-being. This consent also applies to similar procedures in the future. . The procedure has been explained to me. The aim of the treatment is to improve skin problems such as acne, scars, pigmentation spots and sagging skin. I have been advised that, despite the prospect of good results, the probability of complications and the nature of complications can never be precisely foreseen, and therefore no guarantees, either express or implied, can be given with regard to the success or other outcomes of the treatment. . The depth of the peeling and/or microneedling treatment has been discussed in advance with my practitioner. Any complications or problems after the treatment are almost always temporary. Depending on the depth of the peeling and the genetic predisposition of my skin, I may experience the following problems to a greater or lesser extent. Discoloration, swelling and peeling and a dry and tight feeling of the skin for 2 to 14 days. Here and there, wound exudate can also develop and possible crust formation occurs. A previously existing herpes infection may recur as a result of the treatment. In some cases, the redness of the skin can last for a longer period of time. In exceptional cases, scarring or hypopigmentation (discoloration) may occur. Possible complications and side effects have been discussed with me. I am aware that it is important to follow all advice given. I am not allowed to sunbathe or sunbed with the treated skin for 6 weeks after treatment. During this period, the skin should be protected with a sunblock (minimum factor 30) that should be applied every two hours. Under no circumstances should I pull the skins, scrub, peel, wax, steam, visit the sauna or undergo any other skin treatment during the recovery phase. . I hereby declare that I have read (or been read to) this consent form and that I understand this form and the information it contains. I have had the opportunity to ask questions related to the treatment, including questions about risks or alternatives, and I declare that all my questions regarding the procedure have been satisfactorily answered. I declare that I have received verbal explanations and advice for this treatment and that I will follow the advice. I also declare that I have answered questions regarding my medical history to the best of my knowledge. . I agree to be photographed if requested. These recordings are intended to be able to assess the result after treatment and are the property of Gentle Skin Clinic. Use of this for promotional purposes is excluded, unless I give express permission for this. For questions about the treatment or to report a complaint, I can contact Gentle Skin Clinic (www.gentleskinclinic.com).

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  • Leyweg 940H
  • 2545 GV Den Haag
  • 070 225 1230
  • 0651673759 (whatsapp)
  • info@gentleskinclinic.com

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