Sample Medical Profile/informed Consent Form - Fractora
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3SAMPLE MEDICAL PROFILE/INFORMED CONSENT FORM -
FRACTORA ™
Issued by _____________Clinic
Personal Information:
Name:
Date of Birth:
I.D. Number:
Employment:
Address:
Work Address:
Home Telephone:
Business Telephone:
Cell Phone:
Email:
Health questionnaire:
Existing or recent illness
Details:
Details:
Hospitalization / surgery
Details:
Medication
Details:
Medicine intolerance
Details:
Aesthetic procedures in the treatment area
Medical History –
Please inform physician or assistant prior to treatment if you have any of the following
conditions that may make you unsuitable for Fractora treatments.
Pregnancy or nursing
Under 18 years of age
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 cardiac disorders, epilepsy, uncontrolled hypertension, and
liver or kidney diseases
A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area
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
and fragile skin
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
Superficial injection of biological fillers in the last 6 months, or Botox in the last 2 weeks
Use of Isotretinoin (Accutane®) within 6 months prior to treatment
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