Medical History – Please inform doctor/technician prior to treatment if you have any of the following conditions that may make you unsuitable for DIOLAZE™ treatments.
- Pregnancy or nursing
- Under 18 years of age (unless there is parents consent)
- Pacemaker or internal defibrillator
- Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected chemical substance
- Current or history of cancer, especially skin cancer, or pre-malignant moles
- Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications
- Severe concurrent conditions such as cancer, cardiac disorders, epilepsy, uncontrolled hypertension, and liver or kidney diseases
- History of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area (prophylactic treatment may be given)
- Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as excessively/freshly tanned skin
- History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry, cracked, ulcerated, infected and fragile skin
Tattoos, permanent make-up, pigmented lesions (to be kept)
Any medical condition that might impair skin healing
Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction
Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing
Use of Isotretinoin (AccutaneÒ) within 6 months prior to treatment
This form is designed to give you the information you require to make an informed choice of whether or not to undergo treatment with DIOLAZE™ technology. If you have any questions before your treatment please feel free to ask.
- I hereby authorize SYDNEY DERMAL LOUNGE to perform the DIOLAZE™procedure.
- The physician obtained my medical history and found me eligible for treatment
- I have received the following information about the technology:
- DIOLAZE™ is a non-invasive technology that utilizes Diode laser 810nm, for hair removal with highest speed, the best skin cooling system for hairs of dark blond-black colour and skin type I-IV
- No complete clearance is guaranteed
- Treatment requires a number of sessions
- The exact number of sessions is individual
- There may be some discomfort and transient redness and/or swelling associated with treatment
- There is a small risk of adverse reactions
- I understand that taking the treatment course is my choice and that I am free to withdraw at any time, without giving any reason.
- I was told about the possible side effects of the treatment including local pain, skin redness (erythema), swelling (oedema), damage to the natural skin texture (crust, blister, burn), change of pigmentation (hyper- or hypo-pigmentation), and scarring. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.
- I understand that I have to comply with the treatment schedule, otherwise, results may be compromised.
- I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than this above and I authorize the physician or assistants to perform such other procedures if they find them professionally desired.
- I understand that not everyone is a candidate for this treatment and results may vary, therefore, there is no guarantee as to the results that may be obtained
- The procedures to be used to treat my conditions have been explained to me
