Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
93
All persons receiving a test-patch are required to fill out the following form – please include date and
signature
(1)
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.
(2) Are
you
pregnant?
□
Yes
□
No
(3)
Do you have high blood pressure?
□
Yes
□
No
(4)
Have you ever been diagnosed with any form of serious illness?
□
Yes
□
No
If Yes, what type?
(5)
Do you have any medical conditions?
□
Yes
□
No If Yes, what type?
(6)
Do you have a personal or family history of skin cancer?
□
Yes
□
No
(7)
Do you have any allergies?
□
Yes
□
No
If Yes, what type?
(8)
Do you take any medicine for allergies?
□
Yes
□
No
If Yes, what type?
(9)
Are you taking any other medication not mentioned above?
□
Yes
□
No
If Yes, what type?
(10)
Do you have any other medical condition not mentioned above?
□
Yes
□
No
If Yes, what type?
(11) Have you had any facial or body treatment within the last 7 days?
□
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:
