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.
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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:
Yes No Do you smoke or vape tobacco? How many years?How much_ /day?
Yes No Have you ever smoked? How many years? How much /day?
Yes No Do you regularly exercise? If yes, what activity and how often?
Yes No Do you drink alcohol? If yes, how much and how often?
Please indicate if you or any of your immediate family members have any of the following medical conditions:
Active/Chronic Skin Disease
Amyotrophic Lateral Sclerosis (ALS)
Cold sores/Herpes Simplex
Facial Nerve Palsy
Lambert Eaton Syndrome
Recurrent Skin infections
Substance abuse disorder
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? If yes, 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?
Yes No Latex products
Yes No Antibiotics (sulfa containing medications)
Yes No Botulinum toxin
Yes No topical anesthetic or numbing cream (Lidocaine)
Yes No Have you been actively sun bathing lately, if so, when?
Yes No 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
Is you family prone to vascular blemishes?
Varicose Leg Veins
Broken Facial Capillaries
Upper body capillaries
Have you ever visited a dermatologist, plastic surgeon, cosmetic dentist, or other skin
care therapist? IF yes , Please List
Have you ever used Retin A or a similar product? If yes, please list,
Do you use skin products such as moisturizer, cleanser? Explain
Is your skin: Dry Oily Normal Combination Explain
Are you Fair Olive Asian Hispanic Native American African American Please choose
What are you concerns with your skin?
Do you take or have recently been on any of the following medications?
Warfarin or AntiPlatelet Agents
Curarelike Nondepolarizing Blockers
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? If yes, please explain
Have you had problems with excessive scarring or keloid formation in the past? If yes, please 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
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.
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.
You are not a candidate if you are pregnant or breast feeding.
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 CONSE
Iconsent 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, and
injectables like but not limited to (Filler/Toxins/Platelets Rich Plasma aka PRP/ Platelets Rich Fibrin aka PRF/ and PDO Threading)
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. Initial
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. Initial
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. Initial
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. Initial
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. Initial
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. Initial
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. Initial
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. Initial
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. Initial
- 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. Initial
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. Initial
12. I give my consent to the administration of anesthetics. Initial
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. Initial
14. I am UNDER 18 years of age and need parental consent (cosigned below) Initial
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. Initial