Medical History

8 + 12 =

Contraindications

• Pacemaker or internal defibrillator.

• Superficial metal or other implants in the treatment area.

• Current or history of skin cancer, or current condition of any other type of cancer, or pre-malignant

moles.

• History of any kind of cancer *

• Severe concurrent conditions, such as cardiac disorders.

• Pregnancy and nursing.

• Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of

immunosuppressive medications. *

• Diseases, which may be stimulated by light at the wavelengths used, such as history of Systemic Lupus

Erythematosus, Porphyria, and Epilepsy. *

• Patients with history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment

area, may be treated only following a prophylactic regimen.

• Poorly controlled endocrine disorders, such as Diabetes.

• Any active condition in the treatment area, such as sores, Psoriasis, eczema, and rash.

• History of skin disorders, keloids, abnormal wound healing, as well as very dry and fragile skin.

• History of bleeding coagulopathies, or use of anticoagulants.

• Use of medications, herbs, food supplements, and vitamins known to induce photo-sensitivity to light

exposure at the wavelengths used, such as Isotretinoin (Accutane) within last 6 months, Tetracycline, or

St. John’s Wort within the last two weeks. *

• Facial laser resurfacing and deep chemical peeling within the last three months, if face is treated.

• Excessively tanned skin from sun, sun-beds or tanning creams within the last two weeks.

• As per the practitioner’s discretion, refrain from treating any condition, which might make it unsafe for

the patient.

(*) Marked conditions may be treated at the discretion of, and under the full responsibility of the medical

director/physician, although not recommended. In such a case, a small area should be treated and assessed

a few days later to determine if the patient will tolerate the treatment without developing adverse effects.

Possible side effects

Although these effects are rare and expected to be transient, any adverse reaction should be immediately

reported to the physician. Side effects may include any of those conditions listed below. Side effects may

appear either at the time of treatment or shortly after. Some dark-skinned patients may have a delayed

response one-to-two days after treatment and should be evaluated post-test accordingly.

The side effects may include:

• Discomfort

• Excessive skin redness (erythema) and/or swelling (edema)

• Damage to natural skin texture (crust, blister, burn)

• Change of pigmentation (hyper- or hypo-pigmentation)

• Scarring

Pre-treatment preparations

• Avoid skin irritation or intentional skin tanning. Sunblock is advisable when outdoors during daylight

hours.

• The patient should discontinue any irritant topical agents for 2-3 days prior to treatment.

• The patient should arrive for treatment with clean skin. There should be no lotion, make-up, perfume,

powder or bath/shower oil present on the skin in the area to be treated.

• A topical anesthetic should be used only as directed by a physician and only if necessary.

• Areas of dental crowns, caps, braces, or other metal dental implants may be more sensitive to

treatment and the clinician may use dental rolls, gauze or a tongue depressor to isolate the area and

make the treatment more comfortable.

Pre-treatment instructions

• Avoid the sun 4-6 weeks before and after treatment until your physician allows it.

• Your Provider may ask you to stop any oral or topical medications or other skin care products 3-5 days

prior to treatment.

• Tanned or darker skin types should not be treated. If treated within 2 weeks of active(natural sunlight or

tanning booth) tan, you may develop hypo-pigmentation (white spots) and this may not clear for 2-3

months, or even longer.

• The use of self-tanning skin care products must be discontinued 1-2 weeks prior to treatment. Any

residual self tanner must be removed prior to treatment.

• Your provider may apply a topical anesthetic for treatment discomfort. This should be removed just prior

to treatment.

Intraoperative care

• The skin is thoroughly cleaned prior to treatment.

• If treating the upper lip, the teeth may be protected with a moist, wet gauze. The gauze also serves to

support the lip during treatment, allowing a surface to push against.

• Safety considerations are important during the laser procedure. The patient and all personnel in the

treatment room MUST wear protective eyewear during the procedure to reduce the risk of eye injury.

Your provider will take all necessary precautions to ensure your safety and comfort.

• Multiple treatments may be necessary

Inform us

Inform us if you take one of the following medication

Isotretinoin

(Accutane)

Tretinoin (Retin-A)

Anticancer

Chlorambucil

Cyclophosphamide

Antihypertensives

Captopril

Dilitiazem

Methyldopa

Minoxidil

Nifedipine

Promethazine

Thioridazine

Thiothixane

Trifluoperazine

Thioflupromazine

Trimeprazine

Nifedipine

Propranolol

Quinidine

Gluconate

Quinidine sulfate

Verapamil

Dacarbazine

Fluorouacil

Flutamide

Mercaptopurine

Methotrexate

Procarbazine

Thioguanine

Vinblastine

Antidepressants

Amitriptyline

Amoxapine

Clomipramine

Doxepin

Imipramine

Isocarboxazid

Maprotiline

Phenelzine

Protriptyline

Trazadone

Trimipramine

Antiepileptics,

Sedative, Muscle

Relaxants

Carbamazepine

Cyclobenzaprine

Diazepam

Meprobamate

Phenobarbitol

Phenytoin

Antihistamines

Antimicrobials

Ciprofloxacin

Clofazimine

Dapsone

Demeclocycline

Doxycycline

Enoxacine

Flucytosine

Griseafulvin

Ketoconazole

Lomefloxacine

Methacycline

Minocycline

Nalidixic acid

Narfloxacin

Ofloxacin

Oxytetracycline

Pyrazinamide

Sulfa drugs

(Bactrim, Septra,

Tetracycline)

Antiparasitics

Bithionol

Chloroquine

Pyruvinium

pamoate

Quinine

Thiabendazole

Antipsychotics

Chlorpromazine

Cardiovascular

Amiodarone

Atenolol

Captopril

Diltiazem

Disopyramide

Diclofenac

Fenoprofen

Flurbiprofen

Indomethacin

Ketoprofen

Meclofenamate

Naproxen

Phenylbutazone

Piroxicam

Sulindac

Others

Bergamot oil

Oils of citron,

lavender, lime,

sandalwood

Benzocaine

Clofibrate

Oral contraceptive

Meclofenamate

Naproxen

Phenylbutazone

Piroxicam

Sulindac

Others

Bergamot oil

Oils of citron,

lavender, lime,

sandalwood

Benzocaine

Clofibrate

Oral contraceptive

Etretinate

Gold salts

Hexachlorophene

Lovastatin

St John’s Wort

Gmethylcoumarin

Diuretics

Acetazolaminde

Amiloride

Bendroflumethiazide

Benzthiazide

Chlorothiazide

Furosemide

Hydrochlorothiazide

Hydro flumethiazide

Methyclothiazide

Metalazone

Polythiazide

Quinethazone

Trichlormethia-zide

Hypoglycemics

Acetohexamide

Chlorpropamide

Glipizide

Tolazamide

Tolbutamide

NSAIDS

Diphenhydramine

Terfenadine

Tripelennamine

Haloperidol

Perphenazine

Prochlorperazine

Chlorprothixene

Fluphenazine

Azatadine

Clemastine