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Adora Body Sculpting Clinic

3720 Tampa Road Palm Harbor, FL 34684 (727) 787-5476 2306 Ashley Oaks Circle, Suite 101 Wesley Chapel, FL 333544 (813) 991-0088 1107 Professional Park Drive Brandon, FL 33511 (813) 681-5476 4248 Town Center Blvd, Suite 4 Orlando, FL 32837 (407) 857-5476

PRE-TREATMENT ADVICE TO PATIENT: Avoid tanning and any use of tanning products (i.e. self tanners) for 4-6 weeks before treatment with IPL. Use a sunscreen when you do go out in the sun of SPF 30 or higher. Do not pluck, use hair removal creams, wax or have an electrolysis treatments for approximately 6 weeks prior to your treatment. These methods of hair removal will affect what is being treated and MUST be avoided. You MUST shave prior to coming in for each treatment. You may shave before and during the course of treatments ONLY. Please be prepared to inform us of any light sensitive medication you might be using (such as antibiotics etc. - St. John Wart etc.) The best colors to wear when receiving body work (such as bikini line or underarms) are white.

POST-TREATMENT ADVICE TO PATIENT: Shortly after treatment areas may be tender, slightly red and/or swollen. This reaction usually disappears within a few hours. Blisters may occur in sensitive areas such as bikini line and neck areas. Oozing, crusting and scabbing may occur within 1-3 days. (This is a "worst-case" scenario!) Do not pick or remove scabs. If crusting or scabs appear, apply antibiotic ointment (Polysporin, Bactroban, Fucidin or Hydrocortisone) twice daily until healed. The area will heal in 5-7 days. If you experience itching, antihistamines such as Benadryl may be taken 1-3 days if required. Do not use any other hair removal methods or products on the treatment area during the course of your IPL treatments as it will prevent you from achieving you best results. You MAY shave. For the first 2-3 days apply an ice pack for 15 minutes a few times a day if you have swelling. Many people do not experience this. Makeup may be used after treatment unless epidermal blistering occurs (very rare). Use moisturizer under makeup to facilitate exfoliation of the dead hairs. After each treatment avoid sun and use sun screen of SPF 30 or higher to prevent the chance of dark or light spots from occurring. Be gentle with your skin. Treat it as if you have just received a mild sunburn. Feel free to bath and shower as usual, but be kind to your skin--no abrasive scrubbing. Note: Stubble representing dead hair being shed from the hair follicle will appear within a day or two of treatment. 2-21 days from the treatment date the treated hair should fall out. Hair re-growth occurs at different rates at different areas of the body. New hair growth will not occur for at least 2-3 weeks.

2011 by Adora Body Sculpting Clinic

Adora Body Sculpting Clinic

3720 Tampa Road Palm Harbor, FL 34684 (727) 787-5476 2306 Ashley Oaks Circle, Suite 101 Wesley Chapel, FL 333544 (813) 991-0088 1107 Professional Park Drive Brandon, FL 33511 (813) 681-5476 4248 Town Center Blvd, Suite 4 Orlando, FL 32837 (407) 857-5476

IPL HAIR REMOVAL

How it Works and What to Expect

Since all hair removal IPLs target melanin, the best candidates for IPL hair removal are individuals with light skin and dark hair. A dark hair contains melanin and has a plethora of melanin surrounding the dermal papilla, or hair root. The melanin granules absorb the laser energy, which in turn produces a thermal effect. This heating action is what damages the hair follicle. The projected number of treatments needed is 6-10. When you are ready for your treatment, the hair in that area will be clipped or shaved off. We want as much of the IPL energy as possible to be absorbed by the melanin near the hair root. If we left hair on the surface of your skin, the IPL energy would vaporize it and we would lose too much of the IPL energy on the surface of the skin. Within 10-20 days, the treated hair will fall out. It will look as if it is growing, but be patient. Deeper, darker hairs will take more time to fall out than shallower hairs. You may shave or clip those hairs if needed before they fall out, but do not use your tweezers and try to pull them out. Let them take their own time to completely dry up and fall out. You may also bleach treated hairs while you are waiting for them to fall out. You should wait 4-6 weeks after your last tanning session before you start your laser hair removal treatments. The melanin in your skin seems to be `activated' when you tan. Activated melanin will heat more quickly when exposed to the IPL energy, and therefore afford a higher potential for burning the skin or causing pigment changes. You should plan your IPL treatments 4-6 weeks after your last electrolysis treatment or waxing session. You will receive the most economic benefit with IPL hair removal if you have a high density of hair growing in the desired treatment area. Adora Body Sculpting Clinic utilizes state of the art IPL that the FDA has cleared for "Permanent Hair Reduction." As with any personal service of this type, there are always risks involved. As with traditional electrolysis, the risks are hyper-pigmentation, hypo-pigmentation, and burning. Hyper-pigmentation is a darkening of the skin, much like a tan. It could last anywhere from a few days to a few months. Hypo-pigmentation is just the opposite. It is a lightening or bleaching of the skin. If the IPL energy is too high, it could produce a burn. If it was intense enough, it could scar. The treatment is described by many as being similar to being `popped' by a rubber band. Treatment is so fast that most people do not mind what little discomfort they feel. Upper lips can be done in one minute, both underarms in 3 - 5 minutes, and a bikini line can be treated in 10-15 minutes! Hair removal has never been so fast! Just after treatment, your skin will be warm, and possibly flushed with color. You may also notice some erythema, or puffiness. We may apply a topical ointment or lotion to your skin to soothe and cool it, and then apply a cold damp cloth to cool the area down at your request. You should avoid rubbing or scrubbing the area for 24 hours. Pat or gently cleanse the area instead. We want you to treat your skin as if you had just received a mild sunburn. Treatments are delivered 6-8 weeks apart. We will schedule your next treatment each time you visit the clinic in order for you to receive optimum results. Even though you may not see hairs growing in the area when you return for your next treatment, there are hairs growing under your skin that you will not be able to visibly see. As we perform your treatment, you will see obvious skin response that will be your indication that a good treatment has been obtained. Adora Body Sculpting Clinic uses only state of the art equipment and highly trained professionals to operate our equipment. You are in the best possible hands for this therapy! You should always call or email us with any of your questions. We are here to help you eliminate your unwanted hair as quickly and effortlessly as possible. This new technology is truly exciting. Let us show you how to free yourself of your unwanted hair.

2011 by Adora Body Sculpting Clinic

Adora Body Sculpting Clinic

3720 Tampa Road Palm Harbor, FL 34684 (727) 787-5476 2306 Ashley Oaks Circle, Suite 101 Wesley Chapel, FL 333544 (813) 991-0088 1107 Professional Park Drive Brandon, FL 33511 (813) 681-5476 4248 Town Center Blvd, Suite 4 Orlando, FL 32837 (407) 857-5476

Patient's Name _____________________________________________________________________________________________

First

Middle

Last

Address ______________________________________________________________________________________ Street & Apt # City State Zip Home Phone ___________________ Cell Phone ________________________ Other Phone _________________ Any Restrictions for contacting you? No Yes Email __________________________________________

Contact Restrictions ____________________________________________________________________ Age _____ Birthdate _______________ Gender Female Male

Patient's Employer

______________________________________ Occupation ______________________________ Yes No

Work Phone ________________________ Ext ________ Is it okay to call you at work:

Address _____________________________________________________________________________________ Street & Suite # City State Zip

How did you hear about Adora Body Sculpting Clinic : (Mark

all that apply)

Value Guide Bay Magazine Television

Billboard

Internet

Tampa Bay Magazine

Saver's Digest

Friend/ Relative: _________________________

Doctor: ________________ Yes No

Other: _______________

If you were referred by a specific person, may we thank them?

Patient Profile History :

(Please list all)

Allergies ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Medications ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Have you ever taken Accutane? __________ When ________ Dosage ________ Months _______ Have you used Tretinoin? ________ % ______ Do you have herpes simplex? ________ Birth control pills? ______ Currently pregnant? _____ Breast feeding? ________ Attempting Pregnancy? ________ Hair Removal? ____________________________________________________ Wax Electrolysis Laser

Permanent make-up? __________________________ Tattoos ___________________________________________

2011 by Adora Body Sculpting Clinic

Previous Resurfacing Procedures (please

give dates)

CO2 _____ Erbium _____ Dermabrasion _____ Peels: Phenol ____ TCA ____ Glycolic ____ Salicyclic _______ Other treatments ______________________________________________________________________________

Home Skin Care Products

Cleanser ___________ Times/day _______________Toner/Astrigent __________________________________ Moisturizer ____________________ Eye Cream __________________ Exfoliator ________________________ Sunscreen use __________________ Other _______________________ Make-up _________________________

Areas of Concern

Hair

Spider Veins

Rosacea Skin elasticity

Lines/wrinkles Acne scars

Skin Texture

Even color tone

Psoriasis/ Exzema

Acne (pimples, whiteheads, blackheads)

Skin disorder _________________________ Other concerns ___________________________________________

Patient Skin Analysis

Oily

X-dry

Dry

Normal

Combination

Thick

Thin

Normal

Other

Wrinkles ______ Fine _____ Deep _____

Acne _______ Type ______ Acne scars ___________________

Other scarring _________________________________________________________________________________ Keloids _______________________ Scarring _______________________ Pigmentation _____________________ Telangiectasias _________________ Milia __________________________ Comedones _____________________ Enlarged Pores _________________ Elastosis _______________________ Kertosis _________________________

Skin Color Analysis

Caucasian Asian Hispanic light

light

medium dark

dark

very dark

Ethnic Combination (German. Italian, Irish, Puertro Ricans, etc.) Please Specify ___________________________________ Parents(If known) ________________________________

medium medium light

very dark very dark dark

light

dark medium dark

African American Indian light

very dark Grandparents(if known)_______________________

medium

very dark

2011 by Adora Body Sculpting Clinic

Skin Type: (Please

mark the one that best describes your skin) Never tans, always burns (extremely fair skin, blonde hair, blue/green eyes)

Skin Type I

Skin Type II Occasionally tans, usually burns (fair skin, sandy/brown hair, green/brown eys) Skin Type III Often tans, sometimes burns (medium skin, brown hair, brown eyes) Skin Type IV Always tans, never burns (olive skin, brown/black hair, dark brown/ black eyes) Skin Type V Never burns (dark brown skin, black hair, black eyes) Skin Type VI Never burns (black skin, black hair, black eyes)

Skin Background:

Prolonged sun exposure (in last 3 days) Sunburned at this time Use tanning bed in last two weeks Use chemical tanning solutions Wear sunscreen on regular basis

Financing

Are you interested in our O% financing for three months, six months, or 12 months provided by CareCredit which can be used by many physicians worldwide? Yes No I understand that all services provided are payable on the day service is rendered and I have been made aware that Adora Body Sculpting Clinic has a "No Refund" policy once the procedure has been initiated or products have been purchased.

Signature _______________________________________________________ Date __________________________________________

2011 by Adora Body Sculpting Clinic

HIPAA Consent

I give this practice/clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care options like quality reviews. I give this practice/clinic my consent to use or disclose my protected health information in order to obtain payment for services and/or product. I have been informed that I may review the practice/clinic's Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

Signature: ______________________________________ Patient, parent, or legal guardian

Date: __________________

If signed by patient representative, state relationship to patient: _____________________

2011 by Adora Body Sculpting Clinic

Adora Body Sculpting Clinic

3720 Tampa Road Palm Harbor, FL 34684 (727) 787-5476 2306 Ashley Oaks Circle, Suite 101 Wesley Chapel, FL 333544 (813) 991-0088 1107 Professional Park Drive Brandon, FL 33511 (813) 681-5476 4248 Town Center Blvd, Suite 4 Orlando, FL 32837 (407) 857-5476

I, _______________________________ give informed consent for Adora Body Sculpting Clinic to perform IPL hair removal in the body area/areas identified below: ____________________________________________________________________.

I understand that I must shave any and all areas to be treated with IPL for hair removal prior to Initial my appointment and that I may not pluck, wax or use hair removal creams to remove the hair. I understand that if I arrive at my IPL hair removal appointment without shaving that I will pay a Initial $25 per area Shave Fee. I understand that any areas to be treated with IPL for hair removal must be protected from any Initial direct sun exposure for four weeks before and after each hair removal session. I understand that exposure of my eyes to light could harm my vision and that I must keep the Initial eye protection goggles on at all times. I understand that compliance with the before and aftercare guidelines is crucial for healing, Initial prevention of scarring, and hyper-pigmentation. I understand that I must print, sign and bring this consent with me to my first IPL LHR session.

Initial

I understand that failing to comply with any of the above will result in losing my IPL hair removal Initial session, therefore any money paid for that session or be charged up to a $25 rescheduling fee.

Signed: ____________________________________ Date: __________

2011 by Adora Body Sculpting Clinic

INFORMED CONSENT FORM IPL Hair Removal I understand that IPL hair removal treatment is FDA cleared for permanent reduction only and is intended for epilation of hair and that clinical results may vary with different skin types, hair color, and treatment area. I understand that there is a possibility of rare side effects such as scarring and permanent discoloration as well as short-term effects such as reddening, irritated raised rash, blistering, mild burning, swelling, bruising, infection, bleeding, numbing or temporary discoloration of the skin. ______ (Patient initial) ______ (Dr/Tech initial). I understand that if I have a tattoo or permanent make-up in the area to be treated, there is a possibility of blistering and lightening of the tattoo or permanent make-up. ______ (Patient initial) ______ (Dr/Tech initial). I understand that if I've had sun exposure or used a tanning bed within a 4 week prior, during and post treatment with IPL I risk a possible pigment change or blistering. ______ (Patient initial) ______ (Dr/Tech initial). I understand that this procedure works on the growing hair follicles, not dormant hair. For this reason, complete destruction of all hair follicles from any one treatment is unlikely, and I understand that I will require multiple treatments at a regular scheduled interval to obtain significant, long-term reduction of hair growth. I realize that each individual's treatment response is different; therefore, IPL treatment results may vary and could range in number of treatments to achieve desired results or may be minimal or not help at all. I also understand that it may take up to 4 weeks for the treated hair to fall out after each treatment. ______ (Patient initial) ______ (Dr/Tech initial). I understand that there are other options for hair removal such as electrolysis, waxing & chemical preparations. I understand the difference between these options and IPL treatment, and am choosing IPL as a noninvasive treatment for my hair epilation. ______ (Patient initial) ______ (Dr/Tech initial). I understand and agree that Adora Body Sculpting Clinic may choose to take photos of my treatment area for the purpose of monitoring my progress. ______ (Patient initial) ______ (Dr/Tech initial). I understand that there is a 24-hour cancellation policy, and that a $75.00 minimum fee or loss of treatment will result, if I fail to show or do not cancel at least 24 hours prior to a scheduled appointment. ______ (Patient initial) ______ (Dr/Tech initial). I also understand that once I've started my treatment program there are no refunds. ______ (Patient initial) ______ (Dr/Tech initial). I have received post treatment instructions. ______ (Patient initial) ______ (Dr/Tech initial) Adora Body Sculpting Clinic has explained the contents of this form with me and I understand the nature and purpose of the IPL hair removal treatment, including its risks, possible complications, and the fact that each person's treatment response may be different. Each individual has between 500 and 1000 follicles per square cm, of which many could be dormant and there is no way of knowing if and when they may start growing. I have read and understand this consent form and I agree to its terms and authorize treatment. I further understand that Adora Body Sculpting Clinic cannot guarantee the results and I will not hold Adora Body Sculpting Clinic or its employees responsible for my individual results of the hair removal treatment that I have requested. ________ (Patient initial) ________ (Dr/Tech initial). Print Patient Name: ___________________________________________________________ Signature: ______________________________________________ Date: _______________ (Parent or Guardian if patient is under 18) Witness: _______________________________________________ Date: _______________ Adora Body Sculpting Clinic Patient Survey Date: _____________ Patient Name: ____________________ Email address: ______________________

2011 by Adora Body Sculpting Clinic

Adora Body Sculpting Clinic

3720 Tampa Road Palm Harbor, FL 34684 (727) 787-5476 2306 Ashley Oaks Circle, Suite 101 Wesley Chapel, FL 333544 (813) 991-0088 1107 Professional Park Drive Brandon, FL 33511 (813) 681-5476 4248 Town Center Blvd, Suite 4 Orlando, FL 32837 (407) 857-5476

Would you like to be added to our email list? Yes __ No __ How did you hear about us? (Please circle) Radio Television

Billboard

Direct Mail

Internet

Referral

Please specify? ________________________________________________________________________

Are you interested in: Cosmetic Surgery: Liposuction (Tumescent, Smartlipo MPX or TriPlex): Bikini or Mini Tummy Tuck: Natural Breast Augmentation (Fat Transfers to Breasts): Brazilian Butt Lift (Fat Transfer to Buttocks): Facial Fat Transfers: Hair Restoration: Cellulite: Accent XL (Non-surgical treatment for cellulite & Skin tightening): Anti-Aging: Botox: Facial Fillers (Juvederm, Radiesse and Restylane): IPL Hyper Pigmentation Treatment (Treatment for age or brown spots): PhotoFacial (IPL Facial to rejuvenate and resurface skin): Non-Prescription Treatments: IPL Hair Removal: IPL Vascular Treatment (Treatment of spider veins): Teeth Whitening: Prescription Treatments: Medical Weight Loss Program: Stop Smoking Shot:

Yes Yes Yes Yes Yes Yes

or or or or or or

No No No No No No

Yes

or

No

Yes Yes Yes Yes

or or or or

No No No No

Yes Yes Yes

or or or

No No No

Yes Yes

or or

No No

2011 by Adora Body Sculpting Clinic

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