Return-Path: Delivered-To: dump@elementslaserspa.com Received: from ae86.websitewelcome.com by ae86.websitewelcome.com with LMTP id sM8jKhPaX2Y0Pg0AmxFaOA (envelope-from ) for ; Tue, 04 Jun 2024 22:22:59 -0500 Return-path: Envelope-to: team@elementslaserspa.com Delivery-date: Tue, 04 Jun 2024 22:22:59 -0500 Received: from mta-81-59.sparkpostmail.com ([192.174.81.59]:15374) by ae86.websitewelcome.com with esmtps (TLS1.2) tls TLS_ECDHE_RSA_WITH_AES_128_GCM_SHA256 (Exim 4.96.2) (envelope-from ) id 1sEhEp-003dnM-0P for team@elementslaserspa.com; Tue, 04 Jun 2024 22:22:59 -0500 X-MSFBL: ttdGOyNISsavo+kq00uEcUWST/b4UjlnojtJX+ku3Nc=|eyJyIjoidGVhbUBlbGV tZW50c2xhc2Vyc3BhLmNvbSIsImN1c3RvbWVyX2lkIjoiMSIsInN1YmFjY291bnR faWQiOiI1IiwidGVuYW50X2lkIjoic3VydmV5bW9ua2V5IiwibWVzc2FnZV9pZCI 6IjY2NTUwN2RhNWY2NjFjNzcyMTQ2In0= DKIM-Signature: v=1; a=rsa-sha256; c=relaxed/relaxed; d=wufoo.com; s=scph0817; t=1717557767; i=@wufoo.com; bh=k5OTFIBvDbPZuyEn0OkJrceNX+F/21dqdX62651O2JM=; h=Content-Type:To:Message-ID:Date:Subject:From:From:To:Cc:Subject; b=lfypdmmu8CFMQ/TvBisP+nEwRhCB2tu1+LFZJWu4Sy+D4vXKPEWxSJ6Bb129R947d +16BvHehmxvIFtcFTZL0Vt7TWxRmEBW4+IpSU1I6r27R+w0UXHP9GhQuFF1p2cwBVd wxaBAbtqIR6/anuwuQFEijYOyoGB/4a/JvJEBNOU= Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="UTF-8" To: brookefrere@gmail.com Message-ID: <64.1A.21517.70ADF566@ho.mta2vrest.cc.prd.sparkpost> Date: Wed, 05 Jun 2024 03:22:47 +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=09Brooke=0A=09=09=09<= span class=3D"family-name">Frere=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<= th style=3D"border-top: 1px solid rgb(238, 238, 238); padding: 7px 9px; ver= tical-align: top; color: rgb(34, 34, 34); text-align: left;">=0A=09=09=09Tr= eatment Types to be Performed=0A=09=09=09*=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=09=0A=09=09=09=0A=09=09=09=0A=09=09= =0A=09=09=0A=09=09=09=0A=09=09=09=0A=09=09=09=09Medications=0A=09=09=09=09= =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=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=09
Dark Brown (3)
=0A=09=09=0A=09=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=09
Dark Brown (3)
=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=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=09=0A=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=09Thursday, October 22, 1987=0A=09=09
=0A=09=09=09Email =0A=09=09=09*=09=09= =0A=09=09brookefre= re@gmail.com=0A=09=09
=0A=09=09=09Mobile = Phone Number =0A=09=09=09=09=09= =0A=09=09(916) 223-1774=0A=09=09
=0A=09=09=09Emergency Contact =0A=09=09=09*=09=09=0A=09=09=0A=09=09=09John =0A=09=09=09Forrest =0A=09=09=0A=09=09
= =0A=09=09=09Emergency Contact Phone Number =0A=09=09=09*=09=09=0A=09=09(972) 489-8812=0A=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=09Other Medical Conditions=0A=09=09=09=09=09=09= =09=0A=09=09=09=09
N/A=0A=09=09=09
=0A=09=09= =09=09Known Allergies=0A=09=09=09=09=09=09=09=0A=09=09=09=09
N/A
=0A=09=09=09
=0A=09=09=09=09
N= /A
=0A=09=09=09
= =0A=09=09=09Accutane (isotretinoin) Use in the last Six Months=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=09Aspirin Use in Last Three Days=0A= =09=09=09*=09=09=0A=09=09=09
No
=0A=09=09
=0A=09=09=09Tanning in the Last Seve= n Days=0A=09=09=09*=09=09=0A=09=09=0A=09=09=09
None
=0A=09=09=
=0A=09=09=09Eye Color=0A=09= =09=09*=09=09
=0A=09=09=09Hair Color=0A=09= =09=09*=09=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=
Incidental (3)
=0A=09=09
=0A=09=09=09If Too Long in the Sun=0A=09=09=09*=09=09= =0A=09=09=09
Rarely Burns (3)
=0A=09=09
=0A=09=09=09Turn Brown from Sun Exposure=0A=09=09=09*=09=09=0A=09=09=09
Reasonable Tan (2)
=0A=09=09
=0A=09=09=09Turn Brown Several Ho= urs After Sun Exposure=0A=09=09=09*= =09=09=0A=09=09=09
Oft= en (3)
=0A=09=09
=0A=09= =09=09Face Reaction to Sun Exposure=0A=09=09=09*=09=09=0A=09= =09=09
Normal (2)
=0A=09=09
=0A=09=09=09When did you last expose your body to the sun, tanning = booth, or tanning cream=3F=0A=09=09=09*=09=09=0A=09=09=091 - 2 Months Ago (2)=0A=09=09
=0A=09=09=09Have you exposed the area to be treated to the sun=3F= =0A=09=09=09*=09=09=0A=09=09=09
Hardly Ever (1)
=0A= =09=09
=0A=09=09=09Consent to be Photographed
=0ACheck All Boxes That= Apply=0A=09=09=09*=09=09=0A=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=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 understand that I will not be compensate= d 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
  • =0A=09=09
=0A=09=09=09Electronic Signature =0A=09=09=09*=09=09=0A= =09=09=0A=09=09=09Brooke=0A=09=09=09Fre= re=0A=09=09=0A=09=09
=0A=09=09= =09Date =0A=09=09=09*=09=09= =0A=09=09Tuesday, June = 4, 2024=0A=09=09
=0A=0A =0A=0A=0A=0A = =0A=0A=0A
=0A=0D=0A3D""==0D=0A=0A