Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
95
Are you taking medication that may make your skin photosensitive?
□
Yes
□
No If Yes, what type?
A list of the more common medications which may cause photosensitivity is available from the
consultant. If you are on a course of medication, it is advisable to bring along the data sheet enclosed
with the medication to be checked for contra-indications prior to treatment.
Are you pregnant?
□
Yes
□
No
Do you have high blood pressure?
□
Yes
□
No
Have you ever been diagnosed with any form of serious illness?
□
Yes
□
No If Yes, what type?
Do you have any medical conditions?
□
Yes
□
No If Yes, what type?
Do you have a personal or family history of skin cancer?
□
Yes
□
No
Do you have any allergies?
□
Yes
□
No If Yes, what type?
Do you take any medicine for allergies?
□
Yes
□
No If Yes, what type?
INDEMNITY:
I confirm that the information that I have supplied is true and correct, and that I have read,
understood and accept the above-mentioned information. I also confirm that the consultant has
clarified any questions I did not understand.
I hereby indemnify the operator, the clinic owners and their staff, the franchiser and their
employees and the manufacturer of the equipment from any claims whatsoever.
Client
Name:
Client Signature:
Consultant Signature:
Date:
