E.A.S.T. HP
PATIENT CONSENT FORM

All information will be treated confidentially.

Which of the following are important to you?

Pigmentation

Scarring

Wrinkles

Eye laxity

Skin Tags

Other

Fitpatrick Classification Skin Type

Skin Type I

Skin Type II

Skin Type III

Skin Type IV

Skin Type V

WHAT ARE THE RISKS OF THE EAST SYSTEM?

The EAST HP System presents a relatively safe treatment particularly when compared to more invasive aesthetic procedures. However, no procedure is completely without risk. Therefore, it is important to comply with your doctor’s advice and read the aftercare instructions.

Only benign aesthetic skin conditions can be removed from the skin. It is essential that any skin removal can only be done after specialist confirmation that the skin mutation is benign. There is always the minor risk that after removal of skin mutations scarring may result as well as l lighter or darker skin coloration.

RISKS INCLUDE:

  • Swelling and bruising
  • Scabbing and crusting
  • Skin discoloration
  • Scarring

The risk of hyper- pigmentation is very low but may occur. This is a normal skin reaction and usually disappears within a few months. Avoiding sun exposure and following the aftercare instructions will significantly reduce risks.

HISTORY AND RISK FACTORS

Do you take any acne medications (e.g. Isotretinoin aka Roaccutane)?

Yes
No

Do you regularly use corticosteroids (cream or tablets)?

Yes
No

Do you have a pacemaker?

Yes
No

Do you have any metal implants in your body?

Yes
No

Have you had any Radiation or Chemotherapy in the past 2 years?

Yes
No

Are pregnant or breastfeeding?

Yes
No

Have you had an operation or cosmetic procedure in the last 30 days?

Yes
No

Are you currently on antibiotics?

Yes
No

Do you smoke?

Yes
No

Are you on blood thinning medication?

Yes
No

Do you have any allergies?

Yes
No

In the last 24 hours have you taken medications, aspirin or alcohol?

Yes
No

Do you suffer from any of the following conditions?

Cancer

Auto immune disease

Heart Problems

Hepatitis A, B, C, D, F

Cold Sores

Epilepsy

Bone Disease

Haemophilia

Fever or Infectious disease

CLIENT RELEASE

I declare that I have read and answered the medical questionnaire fully and that I understand the information and the implications of treatment. (If you do not understand any aspect of the information, please ask your therapist for explanation).

I give consent to the proposed treatment process that has been satisfactorily explained to me and that I have the information I require. I give my consent to my therapist and clinic to proceed with the procedure.

I understand the importance of aftercare as explained to me by my therapist and have read and understood the aftercare instructions on this form.

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