3Max CoolShaping Consultation
PATIENT INFORMATION
Full Name
*
Date of Birth
*
Phone
*
Email
*
Medical History (including any relevant conditions or medications)
*
SKIN DETAILS
Area(s) of Concern:
*
MEDICAL HISTORY
Do you have any of the following?
*
History of keloids or excessive scarring?
Pacemaker or internal defibrillator?
Cold sore outbreaks or genital herpes?
Skin conditions such as eczema, dermatitis, or rashes?
An autoimmune disease such as lupus?
A viral concern such as HIV or hepatitis?
Anticoagulants Therapy?
Melanoma or lesions suspected of malignancy?
Pregnancy or lactation?
Neurological disorders such as epilepsy (LED Lights)?
Infection in the urinary system (Lymphatic drainage)?
Crohn’s Disease (Lymphatic drainage)?
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphedema (Lymphatic drainage)
HAVE YOU RECENTLY:
Used Accutane, topical medications, or antibiotics?
*
Yes
No
Had aesthetic fillers, injectables, or laser treatments?
*
Yes
No
Had any recent exfoliation (mechanical, chemical, Moroccan bath)?
*
Yes
No
Expectations and Goals:
What results are you hoping to achieve with the treatment?
*
Are you aware of the potential side effects and risks?
*
Yes
No
Consent and Understanding:
Have you received information about the procedure and its process?
*
Yes
No
All of the information is true and accurate to the best of my knowledge.
Patient Signature
*
signature
keyboard
Clear
If you are human, leave this field blank.
Submit
