LUMECCA / FORMA-1 - Wake Skin Care LLC

FITZPATRICK SKIN TYPE

LAST EXPOSED TO UV

SUN TANNING BED

SELF-TANNING LOTION

YES NO

PACEMAKER / DEFIBRILLATOR

PACEMAKER DEFIBRILLATOR

ACTIVE SKIN INFECTION (E.G., PSORIASIS, ECZEMA)

YES NO

METAL IMPLANTS

YES NO

SKIN DISORDERS/ CONDITIONS (E.G., KELOIDS, ABNORMAL WOUND HEALING, VITILIGO)

YES NO

CURRENT OR HISTORY OF SKIN CANCER/ OTHER CANCER / PREMALIGNANT MOLES/SUSPICIOUS LESIONS

YES NO

HISTORY OF BLEEDING DISORDERS

YES NO

SEVERE CONCURRENT MEDICAL CONDITIONS (E.G., CARDIAC DISORDERS)

YES NO

USE OF MEDICATION/HERBS INDUCING PHOTOSENSITIVITY

YES NO

PREGNANCY AND NURSING

YES NO

FACIAL LASER RESURFACING / DEEP CHEMICAL PEELING, LAST 3 MONTHS

YES NO

IMPAIRED IMMUNE SYSTEM

YES NO

NEEDLE EPILATION, WAXING,OR TWEEZING, LAST 6 WEEKS

YES NO

DISEASES STIMULATED BY LIGHT (E.G. LUPUS, PORPHYRIA, EPILEPSY)

YES NO

TATTOO OR PERMANENT MAKEUP

YES NO

INTRA-DERMAL OR SUPERFICIAL SUBDERMAL INJECTIONS/FILLERS/GRAFTS

YES NO

ENDOCRINE DISORDERS (E.G., DIABETES, PCOS)

YES NO

DISEASES STIMULATED BY HEAT (E.G. HERPES SIMPLEX)

YES NO

Detail any Medical Condition that you have marked yes to.

Other Considerations

I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment. I understand that there is a possibility of short-term effects such as reddening, mild burning, temporary bruising, and temporary discoloration of the skin, as well as the possibility of rare side effects such as scarring and permanent discoloration. These effects have been fully explained to me

I understand that treatment with this system involves a series of treatments, and the fee structure has been fully explained to me

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes, and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm that I have informed the staff regarding any current or past medical condition, disease, or medication that was taken. I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education, and promotion. I agree to waive, release, discharge, and covenant not to sue Invasix, Inc. d/b/a InMode (“InMode”) and its employees, agents, and representatives from any liability, loss, cost, damage, expense, claim, or lawsuit whatsoever for any and all injury, loss, illness, harm, cost, expense, or damage related to the treatment, including any negligent acts or conduct by InMode and its agents, employees, and/or representatives (collectively, “Claims”). I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

Helpful Links

We welcome clients from:

Wake Forest, Apex, Cary, Carrboro, Chapel Hill, Clayton, Dunn, Durham, Fuquay-Varina, Garner, Henderson, Holly Springs, Knightdale, Louisburg, Morrisville, Raleigh, Rocky Mount, Rolesville, Smithfield, Wendell, Wilson, and Zebulon, NC

HydraFacial Certified

Wake Weekly’s Best of the Best 2022

First Place – Best Esthetician