Return-Path: Delivered-To: dump@elementslaserspa.com Received: from ae86.websitewelcome.com by ae86.websitewelcome.com with LMTP id gEETHKF9T2ZhEA0AmxFaOA (envelope-from ) for ; Thu, 23 May 2024 12:32:17 -0500 Return-path: Envelope-to: team@elementslaserspa.com Delivery-date: Thu, 23 May 2024 12:32:17 -0500 Received: from mta-81-40.sparkpostmail.com ([192.174.81.40]:8348) by ae86.websitewelcome.com with esmtps (TLS1.2) tls TLS_ECDHE_RSA_WITH_AES_128_GCM_SHA256 (Exim 4.96.2) (envelope-from ) id 1sACIa-003cjB-34 for team@elementslaserspa.com; Thu, 23 May 2024 12:32:17 -0500 X-MSFBL: w4fixY1ovWHP9gmLJp08DzvT1sZBB6aWCbQS3gig5Vc=|eyJzdWJhY2NvdW50X2l kIjoiNSIsImN1c3RvbWVyX2lkIjoiMSIsInRlbmFudF9pZCI6InN1cnZleW1vbmt leSIsInIiOiJ0ZWFtQGVsZW1lbnRzbGFzZXJzcGEuY29tIiwibWVzc2FnZV9pZCI 6IjY2NDU5NTdkNGY2NjE4N2I2MDE2In0= DKIM-Signature: v=1; a=rsa-sha256; c=relaxed/relaxed; d=wufoo.com; s=scph0817; t=1716485525; i=@wufoo.com; bh=x7sPDYZy7Xmn10S+WrlOqbEGLDHjYpHLiGYjMhkdgNc=; h=Content-Type:To:Message-ID:Date:Subject:From:From:To:Cc:Subject; b=QnW5hGENOMBbxS925WxSYB6G2t5EpJDBaIvKkynqQgsc5AmkAth83Wu4p0uYOHVZ9 ceHjrUjGXWEAFDDnOeNn0y6lVHmD4bKOneGxyyoRx3lfb5gelaR28sQMndHUQk8NGC YnNA5qpDMZ/L0/YwwmnUxqNSthkHrYzBGJj9sNmM= Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="UTF-8" To: audreyscouller@gmail.com Message-ID: <61.0E.14500.59D7F466@hb.mta2vrest.cc.prd.sparkpost> Date: Thu, 23 May 2024 17:32:05 +0000 MIME-Version: 1.0 Reply-To: team@elementslaserspa.com Subject: Copy of New Client Information From: "Elements Laser Spa" X-Spam-Status: No, score=-7.1 X-Spam-Score: -70 X-Spam-Bar: ------- X-Spam-Flag: NO =0A=0A=0A=0A=0A=0A=0A=0A=0A=0A=0A= =0A=0A
=0A
Informed Consent Benign = Vascular, Pigmented Lesion , Skin Rejuvenation Treatment

=0A<= br />=0AI have requested that the provider rejuvenate my skin and treat my = benign vascular and/or pigmented lesions. The procedure planned is a non=E2= =80=90invasive treatment using an intense pulsed light (IPL) and/or laser d= evice.
=0A
=0AI have fully disclosed my medical history to my pro= vider and I understand that the treatment may not be performed if any of th= e following apply to me:
=0A1. Pregnant
=0A2. Excessive sun expos= ure or tanning
=0A3. Active cold sores
=0A4. Connective tissue di= sease
=0A5. Autoimmune disease
=0A6. Vitaligo
=0A7. Accutane= use within the past one year
=0A8. History of keloid scarring
= =0A9. Tattoo or permanent make=E2=80=90up in the area to be treated
= =0A10 Implanted pacemaker or defibrillator
=0A11.Use of medications th= at increase photo=E2=80=90sensitivity
=0A12.Use of blood thinners such= as Coumadin or aspirin
=0A
=0APossible risks of the procedure in= clude slight discomfort or pain during and following the procedure, purpura= , swelling, redness, bruising, scarring, blistering, secondary infection, h= ypopigmentation (skin lightening) and hyperpigmentation (skin darkening). U= se of iron supplements increases the risk of skin pigmentation. Skin pigmen= tation may take several months to resolve and may not resolve completely. U= nprotected sun exposure in the weeks following treatment increases the risk= of pigmentation and the time needed for pigmentation to resolve. Eye prote= ction must be worn during the procedure to avoid serious eye damage and pos= sible blindness.
=0A
=0AMultiple treatments are necessary for opt= imum results.
=0AIndividual response to treatment varies.
=0A=0AI have been informed of post treatment guidelines. I understand the r= isks involved in this procedure. I understand that results are not guarante= ed. I have had the opportunity to ask any questions and all questions have = been answered to my satisfaction.


=0A=0A=0A=09=0A=09=09=0A=09=09<= td style=3D"vertical-align:top;color:#333;width:60%;padding:7px 9px 7px 0;b= order-top:1px solid #eee;">=0A=09=09=0A=09=09=09Audrey=0A=09=09=09<= span class=3D"family-name">Scouller=0A=09=09=0A=09=09=0A= =09=0A=09=0A=09=09=0A=09=09=0A= =09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09<= /tr>=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09= =0A=09=09=0A=09=0A=09=0A=09= =09=09=0A=09=09=09= =0A=09=09=09=0A=09=09=0A=09=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A= =09=0A=09=09=0A=09= =09=0A= =09=0A=09=0A=09= =09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09= =09=0A=09= =0A=09=09= =0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09= =0A=09=0A=09=0A= =09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09= =0A=09=0A=09=0A= =09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09=09=0A=09=09=0A=09=0A=09=0A=09= =09=0A=09= =09=0A=09=0A=09=09=0A=09=09=0A=09= =0A=0A
=0A=09=09=09Name =0A=09= =09=09*=09=09
=0A=09=09=09Date of Birth =0A=09=09=09*=09=09=0A=09=09Saturday, June 8, 1963=0A=09=09
=0A=09=09=09Email =0A=09=09=09*=09=09= =0A=09=09audrey= scouller@gmail.com=0A=09=09
=0A=09=09=09M= obile Phone Number =0A=09=09=09=09=09=0A=09=09(512) 663-8751=0A=09=09
=0A=09=09=09Emergency Contact =0A=09=09=09*=09=09=0A=09=09=0A=09=09=09Ross=0A=09=09=09Scouller=0A=09=09=0A=09=09
=0A=09=09=09Emergency Contact Phone Number =0A=09=09=09*=09=09(512) 351-6542=0A=09=09
=0A=09=09=09T= reatment Types to be Performed=0A=09=09=09*=09=09=0A=09=09
    =0A=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09
  • Intense Pulsed Light (IPL)
    • =0A=09= =09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09= =09=09=09=09=09=09=09=09=09=09=09
=0A=09=09
=0A=09=09=09=09Medications=0A=09=09=09=09=09=09=09=0A=09=09=09=09
Atorvastatin=0A=09=09=09
=0A=09= =09=09Accutane (isotretinoin) Use in the last Six Months=0A=09=09=09*=09=09=0A=09=09=09
No
=0A=09=09
=0A=09=09=09Aspirin Use in Last Three Days=0A=09=09=09<= span class=3D"req" style=3D"color:red">*=09=09=0A=09=09=09
No
=0A=09=09
=0A=09=09=09Tanning in the Last Seven Days=0A= =09=09=09*=09=09=0A=09=09=09
None
=0A=09=09
=0A=09=09=09Eye Color=0A=09=09=09*=09=09=0A=09=09=09
Light Blue, Green, Gray (0)
=0A=09= =09
=0A=09=09=09Hair Color=0A= =09=09=09*=09=09=0A=09=09=09
Blond (1)
=0A=09=09=0A=09
=0A=09=09=09Non-exposed Skin C= olor=0A=09=09=09*=09=09=0A=09=09=09
Pale with Beige Tint = (2)
=0A=09=09
=0A=09=09= =09Freckles on Unexposed Areas=0A=09=09=09*=09=09=0A=09=09=09=
Several (1)
=0A=09=09
=0A=09=09=09If Too Long in the Sun=0A=09=09=09*=09=09=0A= =09=09=09
Burns Sometimes Followed by Peeling (2)
=0A=09=09
=0A=09=09=09Turn Brown from Sun E= xposure=0A=09=09=09*=09=09=0A=09=09=0A=09=09=09
Light Color Tan (1= )
=0A=09=09
=0A=09=09=09= Turn Brown Several Hours After Sun Exposure=0A=09=09=09*=09=09=0A=09=09=09
Sometimes (2)
=0A=09=09
=0A=09=09=09Face Reaction to Sun Exposure=0A=09=09=09*=09=09=0A=09=09=09
Very Resistant (3)
=0A=09=09
=0A=09=09=09When did you last exp= ose your body to the sun, tanning booth, or tanning cream=3F=0A=09=09=09*=09=09=0A=09=09=09
Less Than Two Weeks Ago (4)
=0A=09= =09
=0A=09=09=09Have you expo= sed the area to be treated to the sun=3F=0A=09=09=09*=09=09= =0A=09=09=09
Often (3)
=0A=09=09
=0A=09=09=09Consent to be Photogr= aphed
=0ACheck All Boxes That Apply=0A=09=09=09*=09=09		=0A=09=09
    =0A=09=09=09=09=09=09=09=09=09
  • I understand that treatment areas may be photographed befo= re and after treatment
    • =0A=09=09=09=09=09=09=09=09=09=09=09=09=09=09=09= =09=09=09=09=09=09=09=09=09=09=09=09
  • I understand that my identity will not be disclosed
    • =0A=09=09=09=09= =09=09=09=09=09=09=09=09
  • I underst= and that I will not be compensated for any use of photos
    • =0A=09=09=09= =09=09=09=09
=0A=09=09
=0A=09=09=09Please Check the Box=0A=09=09=09*=09=09=0A=09=09
    =0A=09=09=09=09=09=09=09=09=09
  • I agree that by entering my name below = I am electronically signing this form.
    • =0A=09=09=09=09=09=09=09
=0A= =09=09
=0A=09=09=09Electronic Signature =0A= =09=09=09*=09=09=0A=09=09=0A=09=09=09Audrey=0A=09=09= =09Scouller=0A=09=09=0A=09=09=0A=09
=0A=09=09=09Date =0A=09=09=09*=09=09=0A=09=09Thursday, May 23, 2024=0A=09=09
=0A=0A =0A=0A=0A=0A =0A=0A=0A
=0A=0D=0A3D""=0D=0A=0A<= /html>