Same-Day Consult-to-Treat Consent Form.
If the client answers “YES” to any contraindication questions, provider must evaluate carefully before proceeding.
Medical/Health/Lifestyle Screening
- Are you currently pregnant or breastfeeding?
- Do you have a bleeding disorder, hemophilia, or take blood-thinning medications (e.g., aspirin, warfarin, ibuprofen)?
- Do you have uncontrolled diabetes?
- Do you have a history of keloid or hypertrophic scarring?
- Do you have any heart conditions, pacemaker, or defibrillator?
- Do you have an autoimmune disorder (e.g., lupus, MS, RA)?
- Do you have skin conditions at the treatment site (eczema, psoriasis, active acne, infection, open wounds)?
- Have you recently had Botox, fillers, chemical peels, or laser treatments in the treatment area (within the last 4 weeks)?
- Do you have any known allergies to pigments, lidocaine, epinephrine, tetracaine, benzocaine, or other topical anesthetics?
- Do you currently take antibiotics or immunosuppressive medications?
- Do you have epilepsy or a seizure disorder?
- Do you have a history of fainting, dizziness, or sensitivity to needles?
- Are you prepared to follow aftercare instructions and avoid activities such as swimming, sweating, or sun exposure during healing?
- When was the last time you have taken fish oil supplements and other vitamin supplements? (must discontinue 12-24 hours prior)
- Have you consumed alcohol, caffeine, or recreational drugs in the last 24 hours?
- Have you had sunburn or tanning exposure in the treatment area within the last week?
