Medical History Form
First Name
Last Name
Address
City
State
Postcode
Telephone
Email Address
Date of Birth
Sex:
Male
Family Doctor
Contact Number
Emergency
Contact
Name
Number
Note: Minimum treatment age is 18
Female
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Please answer all of the following questions YES or NO
1. Do you have ANY current or chronic medical illnesses?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
6. Do you take/use ANY systemic/oral steroids (e.g., prednisone, dexamethasone)?
Yes
No
7. Do you have ANY allergies to medications, foods, latex or other substances?
Yes
No
Yes
No
Yes
No
10. Do you have a history of herpes I or II in the area to be treated?
Yes
No
11. Do you have a history of keloid scarring or hypertrophic scar formation?
Yes
No
12. Do you have a history of light induced seizures?
Yes
No
13. Do you have any open sores or lesions?
Yes
No
14. Do you have any history of radiation therapy in the area to be treated?
Yes
No
15. In the last six (6) months, have you used any of the following:
Yes
No
Disclose any history of heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blood
disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing
response, skin photosensitivity disorders, or any other condition or illness.
Please List:
2. Do you have ANY current or chronic skin conditions?
Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting
collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition.
Please List:
3. Are you currently under a doctor’s care?
If so, for what reason?
4. Do you take/use ANY medications (prescriptions and non-prescriptions), vitamins,
herbal or natural supplements, on a regular or daily basis?
Please List:
5. Are there any topical products (both medical and non-medical) that you use on your skin
on a regular or daily basis?
Please List:
Please List:
8. (For women)
Are you or could you be pregnant?
9.
(For women)
Are menstrual periods regular, or have you ever been diagnosed with Polycystic Ovarian
Disorder?
LEVEL 1, 55 EXHIBITION STREET, MELBOURNE VIC 3000 (613) 9639 3922
WWW.FIRSTIMPRESSIONLASER.COM.AU INFO@FIRSTIMPRESSIONSLASER.COM.AU
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 anticoagulants or blood-thinning medications; photosensitizing medications; or antiinflammatory or blood thinning medications?
Please List product name and date last used:
16. In the last three (3) months, have you used any of the following products:
 glycolic acid or otheralphahydroxy or betahydroxyacid acid products; exfoliating or
resurfacing products or treatments?
Yes
No
Yes
No
Yes
No
19. Have you taken Accutane® (or products containing isotretinoin) in the last 12 months?
Yes
No
20. Have you taken Tretinoin (like Retin-
Yes
No
21. Have you had any unprotected sun exposure, used tanning creams (including sunless
tanning lotions) or tanning beds or lamps in the last 4-6 weeks?
Yes
No
22. Have herpes simplex in the area being treated
Yes
No
23. Do you have hepatitis?
Yes
No
24. Do you have any moles or suspect spots under your tattoo?
Yes
No
Please List product name and date last used:
17. Do you have or have you ever had any permanent make-up, tattoos, implants, or fillers,
including, but not limited to, collagen, autologous fat, Restylane®, etc.?
If yes, please list locations on or in the body and dates:
18. Do you have or have you ever had any Botulinums, such as Botox® or Dysport®?
If yes, please list locations on or in the body and dates:
Signature
LEVEL 1, 55 EXHIBITION STREET, MELBOURNE VIC 3000 (613) 9639 3922
WWW.FIRSTIMPRESSIONLASER.COM.AU INFO@FIRSTIMPRESSIONSLASER.COM.AU
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Contraindications (Guide provided by Cynosure Pty Ltd)
Therapy using the PicoSure laser is contraindicated for those patients who have any of the
following listed items. Please circle the appropriate answer below and sign the form at the
bottom. This is to ensure the best outcome of your treatment, so please be sure to read the
form carefully.
Are hypersensitive to light in the near infrared wavelength region
Yes
No
Take medication which is known to increase sensitivity to sunlight
Yes
No
Take or have taken oral isotretinoin, such as Accutane®, within the last six months
Yes
No
Have an active localized or systemic infection, or an open wound in area being treated
Yes
No
Have a significant systemic illness or an illness localized in area being treated i.e. lupus
Yes
No
Have common acquired nevi that are predisposed to the development of malignant melanoma
Yes
No
Have herpes simplex in the area being treated
Yes
No
Are receiving or have received gold therapy
Yes
No
Medications that alter the wound-healing response may interfere with post-treatment healing and may
require special precautions to be taken by a treating physician
Yes
No
If patient known to have a history of healing problems or history of keloid formation physician discretion
is required to determine a feasibility of treatment administration
Yes
No
If patient have a history of skin cancer or suspicious lesions physician discretion is required to determine
feasibility of treatment administration
Yes
No
Chemical or mechanical epilation within the last six weeks may interfere with the post-treatment healing
process, physician discretion is required to determine feasibility of treatment administration
Yes
No
Signature
LEVEL 1, 55 EXHIBITION STREET, MELBOURNE VIC 3000 (613) 9639 3922
WWW.FIRSTIMPRESSIONLASER.COM.AU INFO@FIRSTIMPRESSIONSLASER.COM.AU
Page 5 of 6
INFORMED CONSENT
The PicoSure laser produces an intense burst of light that is absorbed by the lesion or tattoo
selectively. All personnel in the treatment room, including myself, will wear protective
eyewear to prevent eye damage from this intense light.
The sensation of the laser light on the skin is uncomfortable and may feel like a slight
pinprick or the sensation of heat. These sensations may last for a few hours.
Following the procedure, the treated area may blister and have pinpoint bleeding for a few
days. The area should be treated delicately following treatment. The number of treatments
required will vary from patient to patient.
Pigment Changes: The treated area may heal with increased or decreased pigmentation
(coloring). This occurs most often in darker pigmented skin and following exposure of the
area to the sun. It is recommended to protect the treated area from any sun exposure with
an SPF of 40+ for 3 – 4 weeks following treatment. If increased pigmentation occurs, it
usually fades in three to six months; however, pigment changes can be permanent.
Scarring: There is a small chance of scarring including hypertrophic scars or very rarely,
keloid scars. Keloid scars are raised scar formations. To minimize chances of scarring, it is
important that you follow all post care instructions carefully. It is important to tell your
technician about any prior history of unfavourable healing.
I have read and understood all information presented to me above, and I have been given
an opportunity to ask questions before signing this consent.
Consent for treatment of:
Patient Name
Date
Patient Signature
Witness Name
Date
LEVEL 1, 55 EXHIBITION STREET, MELBOURNE VIC 3000 (613) 9639 3922
WWW.FIRSTIMPRESSIONLASER.COM.AU INFO@FIRSTIMPRESSIONSLASER.COM.AU
Page 6 of 6
Your Skin Type Result Score
LEVEL 1, 55 EXHIBITION STREET, MELBOURNE VIC 3000 (613) 9639 3922
WWW.FIRSTIMPRESSIONLASER.COM.AU INFO@FIRSTIMPRESSIONSLASER.COM.AU