Z Medi Clinics and Z Medi Spa

Client Health History

Fill in this form to the best of your ability; please make notes on the back as this is for informational purposes. This form is merely a beginning of our information gathering process. When you make your appointment to meet with a Personal Image Consultant, bring this form (and the Condition Reviews) with you or Text or email to our clinics’ managers as your concerns will be addressed in detail during your 30 minute consultation. *

Height ft/in
Weight

Social History:

Please provide us with the following information regarding your medical history: *

Major or chronic illnesses
All Surgeries (including Cosmetic Procedures)
Current Medications and Supplements
Allergies

Do you smoke or vape tobacco? *

Yes

No

If yes, Do you smoke or vape tobacco? *

How many years?
How much per day?

Have you ever smoked? *

Yes

No

If yes, Have you ever smoked? *

How many years?
How much per day?

Do you regularly exercise? *

Yes

No

If yes, Do you regularly exercise? *

What activity and how often?

Do you drink alcohol? *

Yes

No

If yes, Do you drink alcohol? *

How much and how often?

Please indicate if you or any of your immediate family members have any of the following medical conditions:

Botulinium Toxins

Fillers, PRP, PRF, Exosomes, PDO threads

Medical Laser Procedures, Microneedling

Pellets

Initial
Please List Family Medical Conditions Here

Females only: (must be answered if you are a female)

Do you CURRENTLY take oral birth control or other hormonal supplements? *

Yes

No

If yes, Do you CURRENTLY take oral birth control or other hormonal supplements? *

Please list

Are you CURRENTLY pregnant/breast feeding or attempting pregnancy? *

Yes

No

Date of last menstrual period or menopausal status.

Have you had any previous Allergic Reactions to any of the following?

Latex products *

Yes

No

Antibiotics (sulfa containing medications) *

Yes

No

Botulinum toxin *

Yes

No

Topical anesthetic or numbing cream (Lidocaine) *

Yes

No

Sun Exposure

Have you been actively sun bathing lately? *

Yes

No

If yes, Have you been actively sun bathing lately? *

When?

Do you wear sunscreen daily on sun exposed areas? *

Yes

No

Do you to a tanning salon? *

Yes

No

Are you going on vacation where you will be spending time in the sun soon? *

Yes

No

Skin Questionnaire

Have you ever visited a dermatologist, plastic surgeon, cosmetic dentist, or other skin care therapist? *

Yes

No

If yes, Have you ever visited a dermatologist, plastic surgeon, cosmetic dentist, or other skin care therapist? *

Please list

Have you ever used Retin A or a similar product? *

Yes

No

If yes, Have you ever used Retin A or a similar product? *

Please list

Do you use skin products such as moisturizer, cleanser? *

Yes

No

If yes, Do you use skin products such as moisturizer, cleanser? *

Explain

Is your skin: *

Dry

Oily

Normal

Combination

If yes, is your skin type based on a combination: *

Explain

What are you concerns with your skin? *

Medication History:

If you are taking anything else: *

Please Type in here the names of any of these medication listed above or any other medication you are taking

Have you had previous complications with neurotoxins, or fillers? *

Yes

No

If yes, Have you had previous complications with neurotoxins, or fillers? *

Explain

Have you had problems with excessive scarring or keloid formation in the past? *

Yes

No

If yes, Have you had problems with excessive scarring or keloid formation in the past? *

Explain

I have completed the Health History questionnaire. I am in good physical condition and mental state. I have no physical restrictions, conditions, disabilities or ailments that are not noted here. I am cleared by my health care professional to get treatment from the Z Med Clinics and Med Spas. I will let Z Med Clinic Staff and Med Spas’ staff to know if any medication or documented conditions change. I will not hold to Z Med Clinics and Med Spas Employees, contractors, doctors, providers, injectors, Laser safety officers, officers, owners or anyone related *

Pre and Post instructions Laser, Skin treatments and Injections

Pretreatment Instructions

Precautions to take before your lightbased & skin treatment:

Minimize sun exposure and avoid tanning beds and sunless tanning cream. These decrease the effectiveness of the laser or pulsed light treatment and can increase the chance of posttreatment complications. Remove all makeup, creams or oils prior to treatment. For laser hair removal, ask the esthetician whether the area should be trimmed or shaved. Do not wax or pluck the area to be treated. *

PostTreatment Instructions

Precautions to take following your lightbased & skin treatment:

No rubbing, scratching, picking or pulling the treated area.

No swimming or using hot tubs/whirlpools while redness is present or for at least 2448 hours.

Apply moisturizer trice a day while redness is present.

Apply makeup gently and remove with a soft cloth and a gentle face wash

Discomfort may be relieved by ice packs and acetaminophen. Contact the clinic if there is any indication of blistering or infection. AVOID SUN EXPOSURE! When treatment area is exposed to the sun, use a sunblock with SPF 30 or greater and apply it often (at least every two hours)! *

PreTreatment Instructions Injections

Do NOT consume alcoholic beverages at least 24 hours prior to treatment (alcohol may thin the blood and increase the risk of bruising) Avoid antiinflammatory/blood thinning medications, if possible, for a period of 2 weeks before treatment. Medications and supplements such as aspirin, vitamin E, ginkgo biloba, ginseng, St. John’s Wort, Omega 3/Fish Oil supplements, Ibuprofen, Motrin, Advil, Aleve and other NSAIDS have a blood thinning effect and can increase the risk of bruising and swelling after injections. Schedule your Dermal Filler and Botox appointment at least 2 weeks prior to a special event which you may be attending, such as a wedding or a vacation. Results from the Dermal Filler and toxin injections will take approximately 3 to 7 days to appear. Also bruising and swelling may be apparent in that time period. Sculptra does take longer to see results so plan accordingly with your provider. Discontinue RetinA 2 days before and 2 days after treatment. Reschedule your appointment at least 24 hours in advance if you have a rash, cold sore or blemish on the area. If you have a history of cold sores please let your provider know, they may put you on an antiviral medication prior to treatment. Be sure to have a good breakfast, including food and drink before your procedure. This will decrease the chances of lightheadedness during your treatment. *

PostTreatment Injections

Do NOT manipulate the treated area for 3 hours following treatment. Do NOT receive a facial/massages or microdermabrasion after injections for at least 5 days. Ask your provider if you are not sure about the time frame of certain services. Smile and frowning right after Toxin treatments helps the toxin find its way to the muscle into which it was injected after treated. Do NOT lie down for 4 hours after your Botox treatment. This will prevent the Botox from tracking into the orbit of your eye and causing drooping eyelid. It can take approximately 3 to 7 days for results to be seen. If the desired result is not seen after 2 weeks of your treatment you may need additional units. You are charged for product used. Therefore, you will be charged for product used during any touch up or subsequent appointments. Do NOT perform activities involving straining, heavy lifting, or vigorous exercise for 6 hours after treatment. This will keep the toxin in the injected area and not elsewhere. Fillers and Threads: do not work out for the next 2448 hours. Bruising, swelling, redness and inflammation are common after injections. Please call if you have any questions or concerns. We recommend coming back for a 2 week follow up after all injections. Keep injections sites clean for 35 days after treatment. I am aware of my pre and post instructions and will follow these to the best of my abilities. I have asked Z Medi Spa all questions and concerns and feel prepared for my treatment. *

GENERAL INFORMED CONSENT

I consent to, and authorize the staff of ZMED CLINICS AND MED SPAS, ZMEDI CLINIC PROVIDERS PA, and Z Medi Spa LL employees, providers and/ or staff to perform: laser (Hair Removal/IPL/Skin tightening/Resurfacing/Tattoo removal, YAG, ERBIUM, Acne Laser, Opus Plasma Machine ) services, PDGF+, micro needling and skin (Peels/facials/ect.), injectables like but not limited to (Filler/Toxins/Platelets Rich Plasma aka PRP/ Platelets Rich Fibrin aka PRF/ PDO Threading/ PDGF+ ( PDGF+ treatments, all standard Z Med clinic and Med Spa risks and complications apply, with the additional disclosure that recombinant PDGF (rhPDGF) is used topically and in certain off-label (black-label) indications such as injection and hair rejuvenation; patients should be aware of potential allergic reactions to rhPDGF formulations, that the product is not a drug and not for IV use, outcomes may vary with no guarantee of regrowth or rejuvenation, and contraindications include pregnancy, breastfeeding, active infections, immune disorders, cancer history, or allergies to recombinant proteinsPDGF+ is not a drug, not intended to diagnose, treat, cure, or prevent a disease) and Body Contouring (Vanquish machine ). *

1. The nature and purpose of the treatment(s), its possible benefits, and alternative treatments have been explained to me. Any questions I have regarding this treatment have been answered and explained to my satisfaction. *

2. I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these potential risks. *

3. Possible side effects include, but are not limited to, mild redness, extreme redness, bruising, local swelling, stinging, tenderness, pain, dry skin, flaking, lightening or darkening of the skin, infections, pimples, post inflammatory hyper pigmentation, bumpy appearance, cold sores, vision impairment or scarring. Most side effects are temporary and generally subside within 72 hours. *

4. Rare Side Effects: Blindness and eye damage – The laser used in the Procedure, without protective eyewear, may cause visual loss including blindness. I understand that I will be provided with protective eye shields. I acknowledge that it is important to keep these shields on at all times during the Procedure and that I should also keep my eyes closed in order to protect my eyes from accidental laser exposure. *

5. Rare Side Effects: Scarring is a rare complication of laser assisted treatment, but scarring is possible because the skin surface is disrupted by the laser. To minimize the chances of scarring, it is most important that I follow all postoperative instructions carefully. *

6. Allergic reactions Although uncommon, I could possibly develop an allergic reaction to medicines applied to the treated area and that I could possibly develop an allergic reaction to any medications that may be prescribed for me. *

7. Blood clots in veins and lungs Although extremely rare, it may be possible to develop a blood clot associated with this treatment that goes (embolizes) to the heart and/or lungs. *

8. Painful or unattractive scarring Scarring is a rare complication of laser assisted treatment, but scarring is possible because the skin surface is disrupted by the laser. To minimize the chances of scarring, it is most important that I follow all postoperative instructions carefully. *

9. If I am prone to Herpetic outbreaks (cold sores or fever blisters), I understand that I may need to take any oral antiviral medicine. If necessary, the Z Med Clinic and Med Spas Providers will supply me with the appropriate prescription for this medicine. Pregnancy. I am not pregnant and have had a pregnancy test within the past 24 hours. b. Age. I am between the ages of 25 and 65. c. Pap Smear and Pelvic Exam. I have had a Pap smear and a pelvic exam within the past 30 days, the results of which have been provided to the Clinic. *

10. I acknowledge that NO guarantee or assurance, expressed or implied, has been made by anyone regarding this treatment, or series of treatments, which I have herein requested and authorized. The Z Med Clinic and Med Spas, Z MEDI SPA LLC, Z MEDI CLINIC PROVIDERS PA does not offer refunds to treatments given. *

11. I realize that the procedure may not be successful, and the result may not be as I fully desire. I am aware of ZMED CLINICS AND MED SPAS, ZMEDI CLINIC PROVIDERS PA, and Z Medi Spa LLC no refund policy. *

12. I give my consent to the administration of anesthetics *

13. I agree to adhere to all safety precautions and home posttreatment skin care programs recommended by the Zmed Clinics and Med Spas, Zmedi Clinic Providers PA, and Z Medi Spa LL staff. *

14. I am UNDER 18 years of age and need parental consent (cosigned below)

15. I will inform the ZMED CLINICS AND MED SPAS, ZMEDI CLINIC PROVIDERS PA, and Z Medi Spa LL staff of any complications I may develop, as soon as they may occur. *

Full Name *

Select Date *

Phone *

Email *

Signature *

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Home / Consent Forms

Z Medi Clinics and Z Medi Spa

Client Health History

Social History:

Females only: (must be answered if you are a female)

Have you had any previous Allergic Reactions to any of the following?

Sun Exposure

Skin Questionnaire

Medication History:

Pre and Post instructions Laser, Skin treatments and Injections

PostTreatment Instructions

PreTreatment Instructions Injections

PostTreatment Injections

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